Talk:Chiropractic

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Current Safety Text: Suggestions for improvement

Safety

Further information: Spinal adjustment § Safety, and Spinal manipulation § Safety

Spinal manipulation, the most common modality in chiropractic care, has been increasingly studied in recent years as critics and proponents debate the merits of its efficacy and safety. Spinal manipulation has generally regarded is a safe and effective procedure for the treatment of various mechanical low back pain syndromes. Cervical spine manipulation (particularly the upper cervical spine) has been a source of controversy. Critics have suggested that spinal manipulation is of limited benefit and a risk factor for vertebral basilar stroke and there needs to be more research to support its use whereas chiropractors have countered that cervical manipulation is a safe, effective and cost-effective alternate to conventional medical management for mechanical back and neck pain syndromes. Spinal manipulation poses a slight risk to the practitioner, particularly to the wrists, shoulder, and lumbar spine which may occur during the 'orientation' phase and the dynamic thrust phase of manipulation although these risk has not been quantified.

Spinal manipulation is a regulated/controlled medical intervention and can only be performed by chiropractors and a limited number of physical medicine professionals. Prior to the adminstration of spinal manipulative therapy, absolute contraindications must be screened out. These include inflammatory arthritides, fractures, dislocations, instabilities, bone weakening disorders, tumours, infections, acute trauma as well as various circulatory and neurological disorders. Although most contraindications apply only to spinal manipulation of the affected region, a few emergency conditions, such as visual field defects is an absolute contraindication spinal manipulative therapy. In February 2008, the World Health Organization sponsored Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, the largest and most comprehensive study on neck pain, diagnosis, prognosis and safety to date. This included a consensus of the top experts in the world whose findings were collated using a best-evidence synthesis, which addresses risk, prevention, diagnosis, prognosis and treatment risks and benefits. With respect to the association of VBA stroke and cervical manipulation the study concluded:

1. Vertebrobasilar artery stroke is a rare event in the population.
2. There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age.
3. There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups.
4. no evidence of excess risk of VBA stroke associated chiropractic care.
5. The increased risks of vertebrobasilar artery stroke associated with chiropractic and physician visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache consulting both chiropractors and primary care physicians before their VBA stroke."

A 2007 study which examined over 50 000 chiropractic spinal manipulations had no reports of serious adverse effects. The most common minor side effect was pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder which occurred after, at worst, 16 in 1,000 (0.016%) treatments. Furthermore, the authors concluded that the risk of serious adverse effects was, at worst, 6 per 100,000 (0.006%) spinal manipulations. Despite the controversy and skepticism regarding chiropractic spinal manipulation, The World Health Organization states that "[when] employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems."

Comments on current safety

The current rendition on safety acknowledges the following controversies: a) stroke/VBA, b)common side effects of SMT, c) critics claims d)contraindications to SMT. This all despite the relative risk of 0.000002% of serious injury which is far, far better than meds and surgery for the Tx of similar conditions. Yet Eubulides would have the readers believe that it's severely NPOV and because 1/2 the text is not dedicated Edzard Ernst it is severely lacking. DigitalC, myself, Levine2112 and Dematt feel that the current text is close to NPOV and can be tweaked whereas Eubulides and Quack Guru want a complete rewrite that is tantamount to fear mongering (which has not been addressed when asked). EBDCM (talk) 23:58, 5 March 2008 (UTC)

Where does this frequently mentioned stat come from? .0000002% is one in 500 million!CynRNCynRN (talk) 03:04, 6 March 2008 (UTC)

I would go along with DigitalC's rewrite of this part: Spinal manipulation of the neck may be associated with frequent, mild, and transient adverse effects.[58] The most common minor side effects reported in a 2007 study were new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or armCynRNCynRN (talk) 03:03, 6 March 2008 (UTC)

Thanks, I made that change to #Safety 3, keeping the "transient" as you suggested. Eubulides (talk) 10:16, 6 March 2008 (UTC)

Sometimes a 0 or two gets tossed in there. That should be 1-5 million. My bad! EBDCM (talk) 05:05, 6 March 2008 (UTC)

Take the % off the end of it and you're OK!CynRNCynRN (talk) 06:15, 6 March 2008 (UTC)

This version should be deleted off of Wikipedia. It is not NPOV. QuackGuru (talk) 08:55, 6 March 2008 (UTC)

Thanks for your input Mr. Guru; however a majority here disagree with your assertion. EBDCM (talk) 15:21, 6 March 2008 (UTC)

I think we'll make better progress rewriting #Safety 3 instead. #Safety 3 does not devote 50% to Ernst; it's more like 25%, which is reasonable. Clearly Chiropractic #Safety is strongly POV against safety critics; minor patches will not fix this. Eubulides (talk) 10:16, 6 March 2008 (UTC)

You and quack guru are the only ones who think this. We will not allocate any arbitrary number; it makes for a dull, wooden entry that is easily contested. Safety 3 is a cooked goose, and we've already stuck a fork in it. We will focus on improving the current section which is closer to a consensus amongst the majority of editors here than your rewrite. EBDCM (talk) 15:21, 6 March 2008 (UTC)

I disagree with that claim about what the consensus is. No arbitrary number is being asked for; an approximate value will do, which will allow enough freedom to avoid woodenness. The current Chiropractic #Safety allots way too little space to critical comments, and devotes way too much space to refuting them. Eubulides (talk) 22:36, 6 March 2008 (UTC)

Please re-read my comment. I suggest that the current text (in modified version here) is closer to reaching a consensus than Safety3. Tell me what specific critical comments you want listed or expanded, let's come up with good phrasing and we'll add them in. What specific refutations are you talking about? Task Force and Anglo European? They're both large studies which seemingly debunks a lot of myths, addresses incidence rates for minor and major side effects and as far as I am aware contain the best synthesis of literature re: cervical spinal manipulation and adverse effects. Also, both these studies support the plethora of other studies (which I have not listed due to WEIGHT reasons) which suggest a 1 in a 1-5 million chance of serious, permanent neurological impairment. EBDCM (talk) 22:44, 6 March 2008 (UTC)

I have included another piece of Eubulides' safety3, namely the bit about visual defects as an absolute contraindication, a section now which is beginning to be a bit lengthy, IMO. Still, we will work to make sure we get it right and that all parties can live with it. EBDCM (talk) 23:17, 6 March 2008 (UTC)

There is consensus among Wikipedians for the current Safety section in mainspace to be replaced based on the recent discussions. QuackGuru (talk) 21:04, 9 March 2008 (UTC)

This version was rejected by the community and there is a new and concise version in mainspace. QuackGuru (talk) 02:02, 16 March 2008 (UTC)

Not necessarily, QG. In fact there were no comments from Mar 6-16 which suggests it was dormant. We can look at incorporating both this and the current text that addresses the concerns of both proponents and critics. EBDCM (talk) 04:58, 17 March 2008 (UTC)

There was a lot of work in Another redraft of "safety" (now archived) and in #More comments on safety #3 focusing on the "Safety 3" draft. My assumption, and I think the assumption on the part of others, was that this was to replace Chiropractic #Safety and that the approach of making relatively minor changes wasn't going to suffice. That would explain why this section was dormant: it wasn't the approach that was favored. That is not to say that the revised Chiropractic #Safety is perfect; it's not. But on the whole it's a big improvement on the old one, and a better place to start from. Eubulides (talk) 05:17, 17 March 2008 (UTC)

More comments on safety #3

Here is yet another version, with the contraindication part pared down:

Chiropractic care in general, and chiropractic manipulation in particular, are safe treatments when employed skillfully and appropriately. However, chiropractic treatment is contraindicated for some conditions, such as rheumatoid arthritis, broken bones, hematomas, vertebral dislocations or infection.

Ok, it's an honest mistake, I know Cyndy, but the wording is incorrect. I treat patients with RA. Do I manipulate their spine, no. Do I help improve their biomechanics, function, (soft tissue techniques, neuromuscular reeeducation techniques, medical acupuncture, inflammation levels via natural anti-inflammatories (Omega 3, green tea) and inflammation reducing diets (cut out fats, particularly from dairy and meat products). prescribe them exercises and or programs, etc. Anyways, "chiropractic treatment" is not contraindicated for an RA, but SMT is, particularly to C1 (increased ADI to due transverse ligament laxity/rupture) It is subtle, but it's an important difference to note. EBDCM (talk)

I didn't notice treatment vs manipulation there. BTW, have you followed Dr. John McDougall's work and writings re. diet and arthritis? I've been interested in the diet link to many chronic diseases for almost 20 years.CynRNCynRN (talk) 05:32, 6 March 2008 (UTC)

Actually no, Cyn, I had never heard of him but will look him up now. The diet recommendations for patients with inflammatory arthropathies or inflammation in general really just comes from an appreciation of physiological states and how we can manipulate our internal metabolic machinery by changing the "fuel" that it burns. By decreasing pro-inflammatory diet contents and increase anti-inflammatory compounds (when is the last time you heard an MD prescribe this(!) I know we can help manage symptoms. Inflammation is terrible for the nervous system. Many, many chronic pain states and syndromes have an underlying inflammatory component which munching on Flexerol is not going solve the problem. Patients must be pro-active, and the good doctor teaches them how to take care of themselves. Nature will take care of itself if you provide the right STIMULUS. I think DCs are way ahead of the game in their holistic approach towards health and I'm so glad that nurses have embraced this approach. It's such a fulfilling style of care and permeates to all aspects of the patients life. BTW, are you a nurse practitioner (they're called RN(EC) (extended class) here and I must say they do an excellent job and some deliver superior care than some of our MDs in town. (Disclaimer: I'm not against MDs, I highly respect their clinical skills and knowledge and they should be gatekeeper for most of medicine, but not neuromusculoskeletal medicine. )

McDougall wrote several books, referenced with good studies. I just checked his website...pretty flashy these days. I'll put a link on your user page. No, I'm not an NP, I work on a neuro unit.CynRNCynRN (talk) 06:27, 6 March 2008 (UTC)

Rarely, spinal manipulation of the neck can also result in complications that can lead to permanent disability or death. A serious adverse effect is vertebral artery dissection, a tear in the artery that can lead to stroke. The incidence of severe effects is unknown, due to their rarity, to high levels of underreporting, and to the difficulty of linking manipulation to its adverse effects, although estimates range from 1 in 200,000 to 1 in several million cervical spine manipulations(58)(thiel)

This statement implies (and even states) causation which is not the case. There is an association, but so is there for MD care. That's because as Haldeman et al. concluded, these were strokes in progress and they were seeing a health care provider for help with latent symptoms. Now I know you've stated before that you thought DCs were poor screeners for stroke but I would disagree. We are well taught (at least in Canada) in school for the many hard and soft neurological signs, know how to do a proper cranial nerve exam, screening techniques (5Ds, 3Ns, 1A) etc. We experience daily the benefits of spinal manipulation to the quality of life to patients but that does not mean we adjust indiscriminately (at least not mixers/reformers). There is a time and place for SMT (though that does not preclude one from adjusting a lumbar spine, for example) and most DCs know this well. EBDCM ([[User

talk:EBDCM|talk]]) 05:23, 6 March 2008 (UTC)

Case reports tell us some strokes were precipitated immediately by the manipulation. Some people didn't have neck pain presenting. The Haldeman study is great, but does not cancel out all the other research showing evidence of risk. That study also hints that both DCs and GPs were pretty poor at picking up prodromal s/s of stroke.CynRNCynRN (talk) 06:15, 6 March 2008 (UTC).

Case reports are anecdotal. I also have anecdotal evidence of a patient that had (his first) seizure on his first visit to a chiropractor. He had the seizure before being seen by the chiropractor, while in the treatment room. If the seizure had occured 15 minutes later, we would also be seeing case reports that some seizures were precipitated immediately by manipulation. It is a temporal assocation, from which we CANNOT imply causation. DigitalC (talk) 23:05, 6 March 2008 (UTC)

Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions.(59)

Chiropractic researchers emphasize that medical treatments for neck pain, such as ibuprofen or surgery, are much more dangerous than chiropractic treatment, and that benefits outweigh potential risks.(ref needed).

We don't need to unncessarily play this card and IMO, I would rather not do it. We cannot speak for all chiropractors and I doubt DC/PhDs are spending proving repetitive Tylenol use burns a hole in your stomach. We need to flesh out WHO Task Force more, the conclusions listed (5) go together as they're inter-related and are necessary for sufficient context. Also, we need to acknowledge the breadth of the study because otherwise why should we care about its conclusions? I don't think that you appreciate the magnitude of the study done. If you really are interested in cervical spinal manipulation and neck pain you must get the February isssue of Spine 2008; some of these projects were 6 years in length. The amount of citations, and meta-analyses is impressive. And yet Eubulides wants an Ernst paper (1 man's opinion) to get equal weight with the 500-1000 contributors of the WHO study and the entire Feb issue of Spine. It's ridiculous. Anyways, we are making some progress now and I will incorporate DigitalCs suggestion that you agreed with and attempt to get your edit in there as well. Language will be the key so let's focus on that. EBDCM (talk) 05:05, 6 March 2008 (UTC)

I was about to comment, before I saw your reply, that the Bone and Joint study should have more emphasis in the last paragraph of safety #3, as it is a notable study, as long as the critical studies are cited as well, earlier. Comparison to advil/surgery doesn't need to be there, OK.CynRNCynRN (talk) 05:26, 6 March 2008 (UTC)

How could it be emphasized more? Here is all that the main Task Force source (PMID 18204400) says about chiropractic safety:

"There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke."

The unstruck #Safety 3 summarizes it this way:

"Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions."

How could this be rewritten to emphasize the task force results more? The intent here is only minor editing for brevity; it isn't supposed to omit any of the points of the original. But if something is missing, what is it? Eubulides (talk) 08:49, 8 March 2008 (UTC)

(I moved all this as it was about safety #3, not current safety.) Sorry.CynRNCynRN (talk) 07:06, 6 March 2008 (UTC)

x

Is there another word we can use than critics? It is a WP:WEASEL word. DigitalC (talk) 06:44, 6 March 2008 (UTC)

It's balanced by "proponents". Is it "weasel" to acknowledge that chiropractic has critics?CynRNCynRN (talk) 07:00, 6 March 2008 (UTC)

I agree with Cyn, I think critics is OK because it's balanced out. Perhaps skeptics could be substituted if there is a consensus for that. We just need to make sure that critics/skeptics, contraindications, adverse reactions, etc.. do not have too much weight; especially given the fact that is is much safer than NSAIDs and surgery neither of which have drummed up as much needless (IMO) controversy as SMT. EBDCM (talk) 23:22, 6 March 2008 (UTC)

There are different types of critics. For example, take a look at this website. http://www.vocact.com/index.php QuackGuru (talk) 07:12, 6 March 2008 (UTC)

Protected

I have protected the page due to ongoing edit warring. The protection lasts for one week. Please use that time to establish a consensus on what to include and not include on this talk page. If you come to a consensus before then, you can request earlier unprotection at WP:RFPP. Stifle (talk) 09:34, 6 March 2008 (UTC)

Removal of inappropriate warning tag

This has been discussed at length yesterday[5][6]. Whatever the problems here at Chiropractic, the extension of the Homeopathy warning tag to here is an aggression that would be a false and dangerous policy precedent. I am not involved in Homeopathy, Chiropractic or their articles, although I have voted in a few minor AfD/RfC matters distantly related to Chiro where other ongoing WP policy or POV problems were involved.--I'clast (talk) 18:00, 7 March 2008 (UTC)

I'm not aware of any good reason for a probation tag here. I support the use of the usual, objective remedies such as 3RR, and oppose giving admins extra powers to define users as disruptive according to subjective opinion. --Coppertwig (talk) 19:46, 9 March 2008 (UTC)

We need to give admins super powers to stop all the disruptive people on Wikipedia. QuackGuru (talk) 10:15, 10 March 2008 (UTC)

Safety (oh my)

Further information: Spinal adjustment § Safety, Spinal manipulation § Safety, and Scientific investigation of chiropractic § Safety

Chiropractic care in general, and chiropractic manipulation in particular, are safe treatments when employed skilfully and appropriately. As with all treatments, complications can arise and there are known contraindications and risks.

Absolute contraindications, which prohibit employing manipulation, include rheumatoid arthritis, broken bones resulting from one-time injuries, tumors, hematomas, dislocation of a vertebra, bone or joint infection, and many other factors. Relative complications, which mean the increased risk is acceptable under some conditions, include osteoporosis, double-jointedness, disk herniations, steroid or anticoagulant therapy, and many other factors. Although most contraindications apply only to manipulation of the affected region, there are a few exceptions, for example, all chiropractic cervical treatment is contraindicated by a sudden, severe and persistent headache unlike previously experienced headaches.

Spinal manipulation is statistically associated with frequent, mild and transient adverse effects, which two prospective studies reported occur in 30% to 61% of patients. The most common minor side effects reported in a 2007 study of cervical spine manipulation were new or worsening neck pain (reported for about 7.3% of consultations during the follow-up period), shoulder or arm pain (4.8%), reduced movement or stiffness of neck, shoulder, or arm (3.9%), headache (3.9%), upper, mid back pain (2.5%), numb or tingling upper limbs (1.3%), and fainting, dizziness, or light-headedness (1.1%).

Spinal manipulation, particularly on the upper spine, can also result in rare, serious complications that can lead to permanent disability or death. The most commonly reported serious adverse effect is vertebral artery dissection, a tear in the artery that can lead to stroke. The incidence of severe effects is unknown, due to their rarity, to high levels of underreporting, and to the difficulty of linking manipulation to its adverse effects. Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions. Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown.

Manipulation poses a minor risk to the chiropractor, particularly to the wrists, shoulder, and lumbar spine. The main risky activities seem to be transferring patients to positions and applying dynamic treatments. This risk has not been quantified.

A study concluded, "Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy." Another study stated, "Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements)." Spinal manipulation for the lower back seems to be relatively cost-effective.

Safety (oh my) comments

Here is an expanded version. It is complete and not short. FYI, Neutral point of view is a fundamental Wikipedia principle. NPOV is absolute and non-negotiable. QuackGuru (talk) 05:50, 9 March 2008 (UTC)

My kneejerk reaction is that it's too long for Chiropractic. It is not that much shorter than Scientific investigation of chiropractic #Safety 2, for example. Its last paragraph is not just about safety, it's also about efficacy and cost-benefit, and the safety bit seems repetitive; it can go. Other ways to trim include removing some of the more-detailed statistics and some of the contraindications, and a few other phrases; but then we are approximating #Safety 3 (assuming no strikes), no? Let's put it this way: is there anything crucial in this version that is not in #Safety 3? Eubulides (talk) 08:09, 9 March 2008 (UTC)

I prefer Safety 3, as it is more concise. In addition, the last paragraph seems very out of place. Comments on massage and acupuncture belong on the safety sections of those articles. DigitalC (talk) 09:51, 9 March 2008 (UTC)

Efficacy and cost-benefit is related and this version is not vague. Perhaps bits of this version could be tightened. Please discuss. QuackGuru (talk) 20:02, 9 March 2008 (UTC)

I made some simple adjustments. This version is not too short and not too long and has the detailed facts. Removing the detailed facts creates vagueness. The safety 3 short and vague version is nonsensical. This version is concise as well as detailed. QuackGuru (talk) 20:39, 9 March 2008 (UTC)

• I agree that cost-benefit is related, but one problem at a time. This thread is about Chiropractic #Safety and a replacement for that section should focus on safety. Efficacy and cost-benefit are better left for another (yet-to-be-written) section. Perhaps we can start drafting that section now, but it is a different section.
• What is nonsensical about the #Safety 3 draft? I am referring to the current version, not to older versions that contained so many strikeouts that they were indeed nonsensical. What important points are missing in #Safety 3 but present in #Safety (oh my)? All other things being equal, shorter is better, and there is limited space in this article.

Eubulides (talk) 23:42, 9 March 2008 (UTC)

The safety 3 is a bit vague. For example, see the missing details of the children's study. The safety 3 does not mention risk-beneft or compares spinal manipulations versus other methods. Additions of efficacy and risk-benefit may help with the some of the missing pieces. QuackGuru (talk) 00:03, 10 March 2008 (UTC)

Which missing details are those? Here's what #Safety (oh my) says about children:

Spinal manipulation, particularly on the upper spine, can also result in rare, serious complications that can lead to permanent disability or death.… Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown.

Here's what #Safety 3 says:

Spinal manipulation, particularly on the upper spine, can also result in rare complications that can lead to permanent disability or death; these can occur in adults and children.

I don't see any details missing about adverse effects in children. Neither version gives any details about adverse effects on children in particular. #Safety (oh my) says only one thing about children that #Safety 3 doesn't, namely that spinal manipulation is common among children. But that is not a safety topic per se; it's more of a prevalance-of-chiropractic topic.

As for risk-benefit, if the intended topic of #Safety (oh my) also includes efficacy and cost-benefit, then the section needs to be retitled and a lot more emphasis needs to be placed on efficacy and cost-benefit (currently, it's almost all about safety, which is unbalanced). But that will be quite a bit of work. I'd rather get safety fixed, then worry about efficacy and cost-benefit in new (yet-to-be-written) sections. Eubulides (talk) 00:16, 10 March 2008 (UTC)

Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown.[44] Here is the complete sentence in this version above. Please review this sentence. QuackGuru (talk) 00:20, 10 March 2008 (UTC)

That 17-word sentence makes the following points:

1. Spinal manipulation is common among children.
2. Serious adverse events have been identified among children whose spines have been manipulated.
3. The incidence rate of these events is unknown.

#Safety 3 makes the last two points. It does not make the first one, but (1) is not really a safety issue; it is a prevalence issue, one that might better be made in some other section. #Safety 3 uses 2 words "and children" to make the last two points; that's far more compact than #Safety (oh my)'s 17 words. Let's keep it short. Eubulides (talk) 00:27, 10 March 2008 (UTC)

It is short but missing one point. QuackGuru (talk) 00:31, 10 March 2008 (UTC)

Maybe in introductory sentence to summarize the sections will work. Here is an example:

Spinal manipulation, the most common modality in chiropractic care for adults and children, has been increasingly studied in recent years as researchers evaluate its efficacy and safety. QuackGuru (talk) 00:53, 10 March 2008 (UTC)

• The first half of that sentence ("Spinal manipulation, the most common modality in chiropractic care for adults and children") needs a citation, and would be more appropriate for Chiropractic#Treatment procedures.
• The second half of that sentence is somewhat redundant ("studied" / "evaluated"), a bit questionable ("increasingly"? really? what's the source?), and focuses too much on researchers and too little on chiropractic. The article should focus on chiropractic, and mention researchers only in citations. The topic here is chiropractic, not researchers.

Eubulides (talk) 01:19, 10 March 2008 (UTC)

Okay. This can be archived now to focus on Safety 3. QuackGuru (talk) 10:10, 10 March 2008 (UTC)

Chiropractic#Treatment procedures

Spinal manipulation is the most common modality in chiropractic care.[7]

This might work. QuackGuru (talk) 05:21, 11 March 2008 (UTC)

I added it to the article. Please review. Thanks, QuackGuru (talk) 02:06, 16 March 2008 (UTC)

Can you find a peer-reviewed source instead, QG? I doubt this would be disputed as it is common knowledge, but I know for sure there's a reference out there that is "iron clad". EBDCM (talk) 02:13, 16 March 2008 (UTC)

We're already using the NBCE source for that; it's not published in a peer-reviewed journal, but it's more reliable than a random website, so to help improve things I substituted it. Eubulides (talk) 02:57, 16 March 2008 (UTC)

Sources for effectiveness

Here are some sources for the efficacy and/or effectiveness of chiropractic; the idea is that a companion section to Chiropractic #Safety should be written, that talks about effectiveness. A cost-benefit discussion is also needed and can be done later; these citations are aimed just at effectiveness.

I started looking for sources by using the Pubmed query "chiropractic effectiveness" and looking for reviews published 2005 or later, and added effectivess-related sources mentioned in the safety discussion above. Obviously this is not complete; more searching needs to be done. It's only a start. Eubulides (talk) 17:18, 10 March 2008 (UTC)

Commentary on sources for effectiveness

I hope you don't mind adding straight to the list. Hopefully I didn't mess it up, I've never cited before, and find it a little confusing. DigitalC (talk) 23:16, 10 March 2008 (UTC)

Not at all. And thanks. The main thing is to get a PMID or a DOI or a stable URL; we can worry about the details later. Eubulides (talk) 23:42, 10 March 2008 (UTC)

DOI: 10.1016/j.jmpt.2007.01.009 looks useful for benefit (even though it is a primary source), as well as for integrated-medicine. Another 2 primary sources DOI: 10.1016/j.jmpt.2006.12.011 & DOI: 10.1016/j.jmpt.2006.06.022. Will try to look for more reviews. DigitalC (talk) 23:48, 10 March 2008 (UTC)

I dunno, those all look fairly run-of-the-mill; I may be missing something, but I don't detect anything that would overrule the secondary sources we already have. Generally speaking, a primary source in a crowded area like this should be used only when it's too new to be reviewed and is obviously of high quality and says something new and important. Eubulides (talk) 05:57, 11 March 2008 (UTC)

Is there a reason the literature synthesis by the CCGPP on management of low back pain and related leg complaints has not been included? DigitalC (talk) 22:07, 12 March 2008 (UTC)

No; do you have a citation of the latest version? That would save me the work of tracking it down (which I had to do for ther practice guideline, updated this year, for neck pain). Eubulides (talk) 23:38, 12 March 2008 (UTC)

http://www.ccgpp.org/lowbackliterature.pdf DigitalC (talk) 00:07, 13 March 2008 (UTC)

Thanks; I added that. Eubulides (talk) 05:51, 13 March 2008 (UTC)

Asking Ernst to provide an objective assessment on efficacy on chiropractic is like asking Ted Koren or Terry Rondberg to provide an objective assessment on vaccination. Eubulides, out of curiosity, have you read the paper in question? EBDCM (talk) 15:37, 18 March 2008 (UTC)

• Ernst 2008 (PMID 18280103) is a critical evaluation, and is labeled as such. There is value in citing critical evaluations, so long as they're balanced by pro-chiropractic sources.

I think that you're caught a bit with the use of the false dichotomy fallacy. Things are need not always be labelled as "pro" or "anti" chiropractic, or that's not how I select appropriate citations. I would suggest that you do the same.

The labels can be changed to "critical of chiropractic" and "supportive of chiropractic", but the point remains the same: sources should be cited from both sides of the aisle. Eubulides (talk) 08:33, 19 March 2008 (UTC)

• A nice thing about Ernst 2008 is that it's quite recent and has a concise summary of reviews of chiropractic efficacy in all categories. The other sources listed in this talk section are more specialized.

The Ernst paper is riddled with logical fallacies, unfounded conclusions, severely biased interpretations and focuses almost exclusively on straight chiropractic and chiropractors.

It is a critical review. It is not likely to be to the liking of defenders of chiropractic. But that's OK; we can still cite it. I disagree with most of the above comment. For example, many of the paper's paragraphs talk about mixers as well as straights. Eubulides (talk) 08:42, 19 March 2008 (UTC)

• I have read Ernst's "Efficacy" section carefully; that's all that's needed here.

So have I and we can do MUCH better.

• I am not familiar with Ted Koren or Terry Rondberg's work, but if they write about vaccination I suspect that they are more relevant for some other area (Chiropractic#Vaccination perhaps?) rather than the subject of this section.

They are ultra-straight DCs who follow Palmers principles closely. They are extremists and should not be given the time of day, much like Ernst. EBDCM (talk) 23:30, 18 March 2008 (UTC)

Eubulides (talk) 21:28, 18 March 2008 (UTC)

Efficacy in general

This source is a general criticism of chiropractic; it has a section "Efficacy" which is a useful summary of critical evaluations of the effectiveness of chiropractic care.

• Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.

Spinal manipulation

• Lisi AJ, Holmes EJ, Ammendolia C (2005). "High-velocity low-amplitude spinal manipulation for symptomatic lumbar disk disease: a systematic review of the literature". J Manipulative Physiol Ther. 28 (6): 429–42. doi:10.1016/j.jmpt.2005.06.013. PMID 16096043.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Gay RE, Bronfort G, Evans RL (2005). "Distraction manipulation of the lumbar spine: a review of the literature". J Manipulative Physiol Ther. 28 (4): 266–73. doi:10.1016/j.jmpt.2005.03.012. PMID 15883580.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. PMID 16574972.

• The following reviews are a pair; the first is more critical of chiropractic and the second more supportive. They cover more than just effectiveness, but they have effectiveness sections.

• Homola S (2006). "Chiropractic: history and overview of theories and methods". Clin Orthop Relat Res. 444: 236–42. doi:10.1097/01.blo.0000200258.95865.87. PMID 16446588.
• DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res. 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145.

• Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J. 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Specific conditions

These reviews are from the point of view of the condition, not the treatment; they typically cover chiropractic along with several other treatments. As such, they'd be appropriate only for very brief mentions in Chiropractic.

Neck pain and disorders

• Haldeman S, Carroll L, Cassidy JD, Schubert J, Nygren Å (2008). "The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: executive summary". Spine. 33 (4 Suppl): S5–7. doi:10.1097/BRS.0b013e3181643f40. PMID 18204400.{{cite journal}}: CS1 maint: multiple names: authors list (link) This is an executive summary (which briefly talks about effectiveness) of a series of studies and reviews.

• Hurwitz EL, Carragee EJ, van der Velde G (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386.{{cite journal}}: CS1 maint: multiple names: authors list (link) This is a review of interventions, which contains more detail on effectiveness. It is briefly summarized in the executive summary noted above.

• Vernon H, Humphreys BK (2007). "Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews" (PDF). Eura Medicophys. 43 (1): 91–118. PMID 17369783.

• Kay TM, Gross A, Goldsmith C; et al. (2005). "Exercises for mechanical neck disorders". Cochrane Database Syst Rev (3): CD004250. doi:10.1002/14651858.CD004250.pub3. PMID 16034925. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

• Haneline MT (2005). "Chiropractic manipulation and acute neck pain: a review of the evidence". J Manipulative Physiol Ther. 28 (7): 520–5. doi:10.1016/j.jmpt.2005.07.010. PMID 16182027.

Other musculoskeletal problems

• Arm/neck/shoulder: Verhagen AP, Karels C, Bierma-Zeinstra SM; et al. (2006). "Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults". Cochrane Database Syst Rev (3): CD003471. doi:10.1002/14651858.CD003471.pub3. PMID 16856010. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

• Upper extremities: McHardy A, Hoskins W, Pollard H, Onley R, Windsham R (2008). "Chiropractic treatment of upper extremity conditions: a systematic review". J Manipulative Physiol Ther. 31 (2): 146–59. doi:10.1016/j.jmpt.2007.12.004. PMID 18328941.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Whiplash: Conlin A, Bhogal S, Sequeira K, Teasell R (2005). "Treatment of whiplash-associated disorders—part I: non-invasive interventions". Pain Res Manag. 10 (1): 21–32. PMID 15782244.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Low back pain and related leg: Meeker W, Branson R, Bronfert G; et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-03-13. {{cite web}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

• Lower extremities: Hoskins W, McHardy A, Pollard H, Windsham R, Onley R (2006). "Chiropractic treatment of lower extremity conditions: a literature review". J Manipulative Physiol Ther. 29 (8): 658–71. doi:10.1016/j.jmpt.2006.08.004. PMID 17045100.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Adult scoliosis: Everett CR, Patel RK (2007). "A systematic literature review of nonsurgical treatment in adult scoliosis". Spine. 32 (19 Suppl): S130–4. doi:10.1097/BRS.0b013e318134ea88. PMID 17728680.

Headache

• Biondi DM (2005). "Physical treatments for headache: a structured review". Headache. 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.
• Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain. 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Other problems

• Baby colic: Kingston H (2007). "Effectiveness of chiropractic treatment for infantile colic". Paediatr Nurs. 19 (8): 26. PMID 17970361.
• Fibromyalgia: Sarac AJ, Gur A (2006). "Complementary and alternative medical therapies in fibromyalgia". Curr Pharm Des. 12 (1): 47–57. PMID 16454724.
• Bedwetting: Glazener CM, Evans JH, Cheuk DK (2005). "Complementary and miscellaneous interventions for nocturnal enuresis in children". Cochrane Database Syst Rev (2): CD005230. doi:10.1002/14651858.CD005230. PMID 15846744.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Menstrual cramps: Proctor ML, Hing W, Johnson TC, Murphy PA (2006). "Spinal manipulation for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev (3): CD002119. doi:10.1002/14651858.CD002119.pub3. PMID 16855988.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Nonmusculoskeletal conditions: Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW (2007). "Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research". J Altern Complement Med. 13 (5): 491–512. doi:10.1089/acm.2007.7088. PMID 17604553.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Quality of clinical trials

• Headache: Fernández-de-las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC (2006). "Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache". J Orthop Sports Phys Ther. 36 (3): 160–9. PMID 16596892.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Low back pain: Murphy AY, van Teijlingen ER, Gobbi MO (2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther. 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Patient satisfaction

• Gaumer G (2006). "Factors associated with patient satisfaction with chiropractic care: survey and review of the literature". J Manipulative Physiol Ther. 29 (6): 455–62. doi:10.1016/j.jmpt.2006.06.013. PMID 16904491. This source is already used in Chiropractic but would seem appropriate for an Effectiveness section too.

Primary studies

These are primary studies, and as per WP:MEDRS should not be relied on as heavily as secondary stories.

• Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW (2007). "The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study". J Manipulative Physiol Ther. 30 (6): 408–18. doi:10.1016/j.jmpt.2007.04.013. PMID 17693331.{{cite journal}}: CS1 maint: multiple names: authors list (link) This is probably more useful for a risk-benefit section (which would be some new section after "Effectiveness").

Sources for risk-benefit and cost-effectiveness

These sources attempt to review the risks of chiropractic as compared to its benefits, and/or the cost-effectiveness of chiropractic.

Older sources

These citations predate 2005 and are getting a bit long in the tooth. It'd be better to use newer citations if available, if ones of similar quality can be found. Eubulides (talk) 22:04, 10 March 2008 (UTC)

• Skargren EI, Carlsson PG, Öberg BE (1998). "One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain: subgroup analysis, recurrence, and additional health care utilization". Spine. 23 (17): 1875–83. PMID 9762745.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Di Fabio RP (1999). "Manipulation of the Cervical Spine Risks and Benefits". Phys Ther. 79 (1): 50–65. PMID 9920191.

• Rothwell DM, Bondy SJ, Williams JI (2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32 (5): 1054–60. PMID 11340209.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2003). "Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies". Ann Intern Med. 138 (11): 871–81. PMID 12779297.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. (June 3, 2003). "A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain" (PDF). Ann Intern Med. 138 (11): 898–906. PMID 12779300.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Newer cost-effectiveness sources

• van der Roer N, Goossens ME, Evers SM, van Tulder MW (2005). "What is the most cost-effective treatment for patients with low back pain? A systematic review". Best Pract Res Clin Rheumatol. 19 (4): 671–84. doi:10.1016/j.berh.2005.03.007. PMID 15949783.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Haas M, Sharma R, Stano M (2005). "Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain". J Manipulative Physiol Ther. 28 (8): 555–63. doi:10.1016/j.jmpt.2005.08.006. PMID 16226622.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Canter PH, Coon JT, Ernst E (2006). "Cost-effectiveness of complementary therapies in the United kingdom—a systematic review". Evid Based Complement Alternat Med. 3 (4): 425–32. doi:10.1093/ecam/nel044. PMID 17173105.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. PMID 16574972.

• Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.

Newer risk-benefit sources

• Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW (2007). "The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study". J Manipulative Physiol Ther. 30 (6): 408–18. doi:10.1016/j.jmpt.2007.04.013. PMID 17693331.{{cite journal}}: CS1 maint: multiple names: authors list (link) This is just a single study.

POV issues as of 2008-03-12

2008-03-12 issues list

Here is a list of POV problem areas that I see with Chiropractic as it stands now. Fixing these problems would suffice to remove the NPOV tag. Comments welcome.

I have struck out items that are done. Eubulides (talk) 22:07, 14 March 2008 (UTC)

• Chiropractic #Safety devotes too little to criticism and too much to rebuttal of criticism. #Safety 3 is a draft of a replacement, which should fix the problem. This draft has gone through a lot of edits and is ready to go in.

Agree that #Safety 3 is an improvement that is close to NPOV. I notice a lot of good hard work there. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

Thanks. I put it in. Eubulides (talk) 16:29, 13 March 2008 (UTC)

• Chiropractic #Practice styles and schools of thought spends too much time talking about objective straights and reformers, splinter groups that do not seem to exist any more as organized groups. No citations are given for the discussion of these groups (there is one citation for reformers, but it's a dangling link). The simplest fix is to remove this discussion. (fixed; see #Revision to "Practice styles" below)

Agree. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

OK, please see #Revision to "Practice styles" below. Eubulides (talk) 20:18, 13 March 2008 (UTC)

• Chiropractic #Practice styles and schools of thought's last paragraph, which advocates a D.C.M. degree, cites six sources, none of which talk about D.C.M. This paragraph should be removed, or should be properly sourced and rewritten to remove its advocacy. The existing sources should be removed, or moved to appropriate parts of the article. (fixed by removing the sources; see #Revision to "Practice styles" below)

Agree needs appropriate verifiable clarification. -- Dēmatt (chat) 03:46, 13 March 2008 (UTC)

OK, please see #Revision to "Practice styles" below. Eubulides (talk) 20:18, 13 March 2008 (UTC)

• Chiropractic #Utilization and satisfaction rates has an unsourced claim that needs sourcing. (fixed by removing the claim)

Off the top of my head can't remember that sentence, though anything we had did have sources, just might have to dig it out. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

That sentence was re-added here, on 2008-02-29, with a change log entry "restored well known fact; will provide reference". As far as I know the claim has never been sourced. Eubulides (talk) 05:58, 13 March 2008 (UTC)

• Chiropractic #History has the following non-neutral statements that need rewording: (fixed as shown in the following sub-bullets)
  • *"Palmer had discovered that manual manipulation of the spine could result in improved neurological function." It is controversial whether Palmer's treatment actually improved neurological function.
  • The wording "Nevertheless, the debate about the need to remove the concept of subluxation from the chiropractic paradigm" is slightly biased, and would be more-neutrally phrased as "Nevertheless, the debate about whether to keep the concept of subluxation in the chiropractic paradigm". (fixed)

Agree, though the second is not a complete sentence. Perhaps "..the debate continues about.." -- Dēmatt (chat) 03:46, 13 March 2008 (UTC)

The second quote is taken from the complete sentence "Nevertheless, the debate about the need to remove the concept of subluxation from the chiropractic paradigm has been ongoing since the mid 1960s." The end of the sentence would remain unchanged. Eubulides (talk) 06:00, 13 March 2008 (UTC)

• Many phrases are inserted to strengthen the argument for chiropractic by giving the qualifications of sources when they are favorable to chiropractic. Sources should be mentioned in the citation, not in the main text; there is no need to puff up the main text. The following quotes can be removed (with some rewording necessary to fill the gaps):
  • "the World Health Organization defined" (fixed)
  • "Anthony Rosner PhD, director of education and research at the Foundation for Chiropractic Education and Research (FCER)" Here I discovered that the citation was to a link that no longer works. The text of the citation says "Dynamic Chiropractic Aug. 2006", but the table of contents for the 2006-08-15 issue, the only issue published in August, does not mention Rosner. For now I removed the quote which had the side effect of removing the peacock phrase.
  • "Joseph Janse, DC, ND," (fixed)
  • "Judge Susan Getzendanner, who presided over the Wilk case, opined" (fixed; this fix also addresses some citation and temporal problems)
  • "In 1975, the National Institutes of Health brought chiropractors, osteopaths, medical doctors and Ph.D. scientists together" (fixed)
  • The following issues were fixed by citing DeBoer's paper and quoting it directly rather than including all that POV commentary about it. The same fix addresses the "rallying cry" problems noted below.
    • "Joseph Keating dates"
    • "Kenneth F. DeBoer, then an instructor in basic science at Palmer College in Iowa, revealed"
    • "DeBoer's opinion piece demonstrated"
  • "Chiropractic researchers Robert Mootz and Reed Phillips suggest that" (fixed)
  • "the Ontario Ministry of Health and conducted by three health economists led by Professor Pran Manga"
  • "by Steve Wolk"
  • "by Cherkin et al."
  • "The British Medical Association notes that"

Most of these were placed during a phase of POV wars that required that we attribute statements to particular POV sources. Agree that if we can agree to a NPOV statement without them, I would be much more satisfied. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

The attribution requirement is satisfied by proper citations; there is rarely a need to mention the sources directly in the text, and in the above-mentioned cases the need isn't there. Mentioning the sources and their qualifications in the main text tends to puff up what they say; the puffery isn't needed and when done as often as it's done in Chiropractic it constitutes POV. Mentioning the sources in footnotes is fine and is expected. Eubulides (talk) 06:05, 13 March 2008 (UTC)

• Chiropractic #Medical opposition describes the feud between conventional medicine and chiropractors in a heavily biased way. For example, chiropractors are described by a lengthy quote as having "progressive minds" whereas conventional doctors are said to "have failed to realize exactly what is meant by disease processes". Both sides have attacked and have victories and losses, but the current discussion focuses almost exclusively on attacks by the medical profession, on chiropractic victories, and on areas where chiropractic is said to be superior to conventional medicine. The dispute should be covered neutrally. There is no need for a separate section Chiropractic #Wilk et al. vs. American Medical Association with a lot of detail, for example, unless there is also similar detail devoted to the other side.

Have to look at this closer, but we cannot rewrite history. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

Agreed; the summary of the dispute should be both neutral and accurate. Eubulides (talk) 06:06, 13 March 2008 (UTC)

• Chiropractic #Movement toward science contains language like "empower faculty", "demonstrated the faculty's authority to challenge the status quo, to publicly address relevant, albeit sensitive, issues related to research, training and skepticism at chiropractic colleges, and to produce "cultural change" within the chiropractic schools so as to increase research and professional standards", and "It was a rallying call for chiropractic scientists and scholars." that clearly advocates a viewpoint favorable to the movement toward science. This wording should be reworded or removed. (fixed by removing the POV language and by citing DeBoer directly)

These are words used by V and RS's. Though we could add sentences from WCA suggesting that "science will never be able to capture the essence of subluxation."

Whatever it takes to give a reasonable-neutral summary of that part of history. The current summary is clearly biased toward one side. Eubulides (talk) 06:09, 13 March 2008 (UTC)

• There is no need to mention twice that JMPT is included in Index Medicus, particularly since Index Medicus is no longer published.

Once is enough. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

OK, done. Eubulides (talk) 20:32, 13 March 2008 (UTC)

• The sections Chiropractic #The Manga Report, Chiropractic #Workers' Compensation studies, Chiropractic #American Medical Association (AMA), and Chiropractic #British Medical Association are merely a laundry list of endorsements of chiropractic. These sections should be removed, with their useful content moved to appropriate sections, as citations.

Merge them. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

• Chiropractic #External links should be removed. It contains pointers to a whole bunch of anti-chiropractic web sites with approving words surrounding the citations. It also contains many pointers to pro-chiropractic web sites, without comment. This is POV. Besides, none of the external references meet the criteria set forth in WP:LINKS #What should be linked. Let's just remove them all: Wikipedia is not a link farm. (fixed)

This is a POV issue. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

Yes, it's a POV issue. Does the proposed fix (of removing the section) sound reasonable? At first glance that might seem drastic, but many high-quality articles (such as Hippocrates and Sequence alignment) have no External links sections at all. Eubulides (talk) 20:46, 13 March 2008 (UTC)

I am not married to anything is this article as long as we handle all the issues NPOV. ---- Dēmatt (chat) 15:05, 15 March 2008 (UTC)

OK, thanks, I took the easy way out by replacing the section with a single pointer to the Open Directory linkfarm. Eubulides (talk) 22:34, 15 March 2008 (UTC)

• The lead should reflect the body of the article. The lead currently lacks summaries for some entire sections, including Safety, Scientific inquiries, Vaccination. The overall effect is to minimize the controversial parts of the body.

This could be construed as undue weight violations as the safety section and vaccination section are too big or slanted in terms of giving excess weight to minority held positions and a very rare risk of serious injury with SMT. EBDCM (talk) 03:32, 17 March 2008 (UTC)

That issue can be resolved by following Dematt's suggestion to finish the body first. Eubulides (talk) 05:21, 17 March 2008 (UTC)

Finish the body, then look back at the lead. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

That order sounds reasonable, yes. Eubulides (talk) 06:10, 13 March 2008 (UTC)

• The lead also has a POV phrase that needs rewording: "Today, the progressive view".

See above. -- Dēmatt (chat) 03:41, 13 March 2008 (UTC)

Eubulides (talk) 06:20, 12 March 2008 (UTC)

Comments on assessment

I disagree with much of this assesssment. . . For instance, the Workman's Comp studies were landmark studies and appropriately mentioned. . . hardly mere laundry lists. And "Many phrases are inserted to strengthen the argument for chiropractic by giving the qualifications of sources when they are favorable to chiropractic". . . that seems to be an opinion share by those who would prefer this to be an article which presents arguments against chiropractic. Vaccinations should not have its own section in this article. . . it is a minor point which the opposition tries to play up to be some kind of big deal.TheDoctorIsIn (talk) 00:58, 13 March 2008 (UTC)

I would have to agree here, and say the same about the Manga report. It was a landmark study and derserves to be mentioned. DigitalC (talk) 02:47, 13 March 2008 (UTC)

To "mainstream medicine" folks, the controversy about vaccination among chiropractors is a big deal. It's notable when a significant percentage of group of health professionals recommend against vaccines, or vociferously oppose them, as many do.CynRNCynRN (talk) 04:31, 14 March 2008 (UTC)

FWIW, a chiropractor in Ontario (and I believe the rest of Canada) cannot even comment on vaccines, as they are outside the scope of practice of chiropractic. DigitalC (talk) 05:46, 14 March 2008 (UTC)

I doubt whether it's true of the rest of Canada. See, for example, Injeyan et al. 2006 (PMID 17045098), which asked Alberta chiropractors about their ability to give immunization advice to their patients. And even if it's supposed to be true in Ontario in principle, it's not true in practice; one can easily find websites of chiropractors in Ontario containing advice about vaccination. Here's one example: [8]. Eubulides (talk) 06:24, 14 March 2008 (UTC)

Here's another example from 2004, anti-vax Ted Koren was invited to speak at CMCC, and an outbreak of pertussis was perhaps linked to a chiropractor's advice, http://www.cbc.ca/consumers/market/files/health/vaccines/pg_two.html CynRNCynRN (talk) 20:12, 14 March 2008 (UTC)

That speech and that outbreak predated the rule change that prevented Ontario chiropractors from discussing vaccination.[9] The examples given above were more recent. Eubulides (talk) 22:02, 14 March 2008 (UTC)

The link above (painfree) was not giving advice about vaccination, it was entirely from an educational perspective. 202.161.71.161 (talk) 06:42, 15 March 2008 (UTC)

The link is anti-vaccination propaganda with pictures of skeletons all over it. It's sort of like handing out a pamphlet saying "All doctors are quacks!" with pictures of skulls and crossbones on it, and then afterwards saying "Oh, no, I wasn't giving you advice about medicine, it was entirely from an educational perspective." Perhaps that sort of behavior is technically legal under Ontario's guidelines, but from a practical point of view it means that chiropractors in Ontario can and do advise their patients not to vaccinate. Eubulides (talk) 07:25, 15 March 2008 (UTC)

Hehe, the skeletons are part of the background. It's even on the fitness page. To DCs skeletons are good things ;-) This illustrates the issue about the different types of vaccines (flu vs polio, etc.) There are medical groups opposed to flu vaccine. We need to be careful here. -- Dēmatt (chat) 15:25, 15 March 2008 (UTC)

I guess I overreacted to the skeletons. Still, the text of the page is plenty antivax. Which medical groups are opposed to the flu vaccine? Eubulides (talk) 23:58, 15 March 2008 (UTC)

Perhaps the better question is, what is the efficacy of the flu vaccine? A quick look would suggest that it's not as clear cut as implied by some: http://vaccineinfo.net/immunization/vaccine/influenza/flu_vaccine_facts.shtml.

I dunno, that's just a random antivax web site. One can easily find web sites opposing any form of treatment, including chiropractic treatment. Is there a reliable source indicating that flu vaccine is not efficacious? Something like Tosh et al. 2008 (PMID 18174020) or Jefferson et al. 2007 (PMID 17443504)?

I would suggest that it's not necessarily an "anti-vax" site as suggested, and it does cite sources within the body if was read. Nonetheless, it raises interesting points (such as efficacy being related to age and to a particular strain)and does present the other side of the argument. With respect to purported anti-vax statements on websites, this is against the standard of practice in most Canadian provinces and the CCO has fined members up to 25K for those shenanigans. Nonetheless, we should not pick one example and make attributions, for I can go to MD websites and show them endorsing questionable methods such as homeopathy. We need to be careful with giving fringe POVs too much weight here which seems to be an increasing concern. EBDCM (talk) 01:51, 16 March 2008 (UTC)

The site did look very questionable to me, refs or not. The flu shot is not overwhelmingly effective,as any medical person would admit, but probably worthwhile:"Two randomized controlled trials (in long term care facilities) have evaluated the impact of influenza vaccination of HCP on the outcomes of residents in nursing homes. In one study, staff vaccination was associated with a 43% decrease in incidence of (flu)... In another study crude mortality rates were 42% lower among residents in facilities with higher staff vaccination coverage than those in control facilities. Randomized trials assessing the impact of staff vaccination on patient outcomes in acute care facilities have not been conducted, but low staff vaccination coverage has been correlated with influenza outbreaks in hospitals" CynRNCynRN (talk) 02:21, 16 March 2008 (UTC)

(outdent)BTW, the vaccineinfo.net site is full of false and questionable information! Just do a little digging. For instance, writers question the effectiveness of the rabies vaccine in several articles "the vaccinated person dies anyway". Worldwide, at least 55,000 deaths are still caused by rabies. The post exposure prophylaxis has been 100% effective in the US.It's difficult to find reliable info on vaccines on the net with pages and pages of fear-mongering sites!CynRNCynRN (talk) 19:08, 16 March 2008 (UTC)

About your other point, EBDCM, it is notable that a significant % of DCs are anti-vax, especially when some want to be integrated with mainstream. I am glad that another 'significant percent' of chiropractors are pro-vax....but it is an important controversy in the profession.CynRNCynRN (talk) 02:21, 16 March 2008 (UTC)

Cyn, I agree it's notable, it's just a weight issue. When does 20% constitute a significant %? Remember, that chiropractic is really a two (or 4 depending who you ask) headed monster. No "mainstream" DC is opposed to vax, the lit says it's mostly worthwhile. I'm pro-vax but cannot comment on it professionally due to it's outside my scope of expertise. I just don't want to the many level headed DCs who are either pro or neutral have the "guilt by association" fallacy applied to them. We need to be balanced on this issue. The trend suggests that the anti-vax wing is shrinking from generation to generation and this is important to note, IMO. EBDCM (talk) 02:30, 16 March 2008 (UTC)

It's more than just 20%. Busse et al. 2005 (PMID 15965414) reported surveys of Canadian chiropractors with 40% supporting and 31% unsure and 29% opposed. These were recent (year-2000) graduates of CMCC. The level of opposition reported in the U.S. is even higher; see Campbell et al. 2000 (PMID 10742364). This high level of opposition to an enormously successful public-health strategy remains a significant problem. Eubulides (talk) 02:50, 16 March 2008 (UTC)

Well, that's your interpretation of it. As well, as Dematt suggested while some DCs may oppose a PARTICULAR vaccine, they get labelled as anti-vax. Some vax are more effective and better than others. So again, unless we provide some kind of clarification, the current material is misleading and again does not acknowledge the historical trend that this sentinent is at the very least, softening over the last 100+ years. Also, the current edit fails to acknowledge that part of the opposition is towards MANDATORY vaccination and should let the patients decide. Lastly, DCs approach health care differently (philo) from mainstream med and this is not even acknowledged either in the current text. So, it's either a) undue weight or b) does not adequately explain where oppostion comes from. In any case, in politics if 71% (those not anti-vax) would be considered a landslide. I think this section plays up the anti-vax sentiment too much and is undue weight on straights. Vax is not within the scope of practice of DCs anyways and this isn't even mentioned. EBDCM (talk) 19:09, 16 March 2008 (UTC)

• The abovementioned surveys were not about particular vaccines, or about mandatory vaccination; they were about vaccination in general.
• Adding something about the motivation would make sense. Earlier versions of Chiropractic#Vaccination attempted to explain the motivation, with a quote from D.D. Palmer, but this was removed. Perhaps a better explanation could be supplied.
• The level of opposition to vaccination is extraordinary in chiropractic, compared to conventional medicine; this is notable, even if a substantial minority of chiropractors favor vaccination.
• It might make sense to move "Vaccination" into an "Opposition to medicine" section, as vaccination is an area where chiropractic criticizes conventional medicine. Fluoridation might be another topic to cover in that neighborhood.

Eubulides (talk) 00:27, 17 March 2008 (UTC)

straight chiropractic may criticize vax but contemporary does not. Being neutral on a subject is not a bad thing, necessarily. Ask Switzerland. EBDCM (talk) 03:36, 17 March 2008 (UTC)

It's not that simple. I don't know of any reliable source supporting the claim that contemporary chiropractic (which I assume means mixers) does not criticize vaccination. It's quite plausible that many mixers do criticize vaccination in practice. The ACA (a mostly-mixer organization) used to be more in favor of vaccination than it is now; it is now slightly negative, by favoring exemptions to vaccination laws. Eubulides (talk) 05:31, 17 March 2008 (UTC)

You're reaching here by speculating what individuals MAY think in practice. Also, being neutral on a subject is not a negative thing, it's neutral. Exemptions from mandatory laws is a more libertarian way of thinking than anything else. Also, we should not only focus on the USA; it would be worthwhile to investigate other national positions (i.e. Europe). EBDCM (talk) 23:45, 18 March 2008 (UTC)

Speculation is OK on talk pages. The ACA is not entirely neutral on vaccination; it supports exemptions to mandatory vaccination laws, which is a mildly anti-vaccination position. (The ACA does not support exemptions to quarantine laws, which would be just as consistent with libertarianism; so this is not simply a matter of chiropractors being libertarians, and it has something to do with vaccination per se.) If we can find a reliable source to summarize all the international organizations' positions on vaccination, that would be a good thing, yes. Eubulides (talk) 08:47, 19 March 2008 (UTC)

[outdent]. Fluoridation now? Another condemnation topic? The Doctorisin is perhaps right in his assessment... The use of puff adjectives "opposition to vax is extraordinary" and "substantial minority" is neither necessary nor necessarily true. Also, as a separate and distinct profession with a separate and distinct approach and philosophy it really shouldn't be a matter of "passing judgement" as the tone and weight of the vaccination section does. Also, my point that there has been a historical softening of the anti-vax stance. This section is 8 lines for 2 studies that could easily be edited into 1-2 lines as had previously been done that would acknowledge all the points you are trying to make without getting into puff details that stretch it out and give too much weight to one side of the prof vs. the other. EBDCM (talk) 03:23, 17 March 2008 (UTC)

• The ICA opposes fluoridation of municipal drinking water as a matter of policy [10]. The ACA takes no position now, but a quick check on the web found claims that it formerly supported fluoridation and stopped doing so.[11] Fluoridation is not as important as vaccination for public health, but it still might be worth a brief mention as an example of chiropractic's disagreements with mainstream public health. Eubulides (talk) 05:55, 17 March 2008 (UTC)

This is needlessly inflammatory and the ICA hardly speaks for anywhere near the majority of the profession. We should not consistently give so much weight to fringe groups and their fringe opinions. Chiropractic is free to have different opinions than mainstream med without any condemnation from editors who disagree with this view. Also, you will be setting up a (dangerous) precedent by constantly wanting to include mainstream meds 2c on these issues in this article. I'm tempted to apply the same standards here to medicine and see how far I'd get. Probably reverted within 30s! EBDCM (talk) 23:45, 18 March 2008 (UTC)

I don't see what's inflammatory about summarizing chiropractic organizations' positions on matters of public health. Chiropractic is certainly free to differ from mainstream medicine, but that does not mean the differences should be ignored in a Wikipedia article. Eubulides (talk) 08:53, 19 March 2008 (UTC)

• The "puff adjectives" in question are not in Chiropractic and no proposals have been made to put them in.
• Currently chiropractic is less opposed to vaccination than D.D. Palmer was, but it appears to be more opposed than it was in the early 1990s. Any discussion of historical trends should mention both of these changes.

This is nit-picking. Is it more or less anti-vax now than it historically has been? Unquestionably, yes. IMO does it need to go further (USA I'm looking at you), yes. EBDCM (talk) 23:45, 18 March 2008 (UTC)

It is far less anti-vax now than it was 100 years ago. It is a bit more anti-vax now than it was in the early 1990s. Eubulides (talk) 08:55, 19 March 2008 (UTC)

• Specific suggestions for improving the tone, weight, and brevity of the vaccination section are welcome.

Eubulides (talk) 05:55, 17 March 2008 (UTC)

I hope that once we are done with the editing here on all topics that we can maybe get a well deserved beer (or protein shake if you like). When it feels right hopefully most of us will know it; but for now I'm working on other sections first. EBDCM (talk) 23:45, 18 March 2008 (UTC)

Sorry about the above..wrong dates. Some still have or had anti-vax material on websites, see April 2005 Have any practitioners been fined for going against the prohibition?CynRNCynRN (talk) 07:05, 15 March 2008 (UTC)

The proposal is not to remove the discussion of Workman's Comp studies and Manga report. If they are historically important reports, they should be mentioned. However, they do not each deserve an entire section of their own. That's way overkill. And it raises a POV issue: why do old pro-chiropractic studies get entire sections of their own, whereas old anti-chiropractic studies get no mention at all? The Manga report is 10 years old (and the citation to it is now a dangling link! what's up with that?). The Workman's comp studies are nearly as dated. These are historical references, and as history they are not nearly as important or interesting as dozens of other points about the history of chiropractic. The AMA and BMA sections are also weird; they look like testimonials trotted out at the end of an informercial. If it's important that conventional medicine recognized chiropractic around 1990, the article should just say that and give a citation; there's no need to copy long and boring quotes about it. Eubulides (talk) 06:43, 13 March 2008 (UTC)

Which old anti-chiropractic studies are you referring to? The Manga report and WOrkmen's comp studies could go in the history section, AFAIC, because they are historically important. DigitalC (talk) 05:46, 14 March 2008 (UTC)

I wasn't referring to any old anti-chiropractic studies in particular. The point is that there are some, from reliable sources, and it's NPOV to ignore them while giving entire sections to the pro-chiropractic studies. Please see #Manga report notes below on historical coverage of the Manga report. Eubulides (talk) 05:59, 14 March 2008 (UTC)

Safety section

I see that everyone has put a lot of work into the safety section and with relatively good results over the original version. I note that it took all of you to combine your intellects and POVs t come to something that is reasonable and makes sense. EBDCM, keep your nose clean and collaborate with civility. You are important to this process. ;-) -- Dēmatt (chat) 03:46, 13 March 2008 (UTC)

I would like to note that I also have a few POV issues (or perhaps weight) that should be rectified: the safety section and the very little it dedicates to the Neck Pain Task Force findings (in contrast to Ernst) and the vaccination section. Both are too big and should be shortened. Also, the safety section that is in current place seems not to differentiate between chiropractic and SMT, a frequent problem in conventional medical literature. EBDCM (talk) 01:25, 16 March 2008 (UTC)

• The Task Force source says only this about chiropractic safety:

"There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke."

Chiropractic #Safety summarizes it this way:

"Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions."

How does this omit anything that the Task Force source said?

• Chiropractic #Safety is now half as long as it was when the POV issue was originally raised, so the article is much significantly now in that area, if by "better" one means "spends less time talking about safety".
• Specific suggestions for shortening the wording are welcome. Brevity is a good thing.

Eubulides (talk) 01:50, 16 March 2008 (UTC)

Well, for example, why should we care about the Task Force, or Ernst, for that matter? What makes THEIR research notable and worthy of inclusion? Context should be provided. For example, the Task Force included a consensus of the top experts in the world whose findings were collated using a best-evidence synthesis, which addresses risk, prevention, diagnosis, prognosis and treatment risks and benefits.[70] Can you say the same about Ernst? Why should they be given the same weight if not? Furthermore,with respect to the association of VBA stroke and cervical manipulation the study concluded 1)Vertebrobasilar artery stroke is a rare event in the population. 2)There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age. 3) There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups. 4)no evidence of excess risk of VBA stroke associated chiropractic care. 5) The increased risks of vertebrobasilar artery stroke associated with chiropractic and physician visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache consulting both chiropractors and primary care physicians before their VBA stroke."[71] Do you not think that the bolded text is a pretty big omission? If not, why? Isn't the bolded text the "bottom line"? The major conclusions/findings should be presented in full, not just a quick one liner. EBDCM (talk) 02:02, 16 March 2008 (UTC)

• The task force's report covers many issues; Ernst focuses on just safety, which is the issue at hand. The task force's broad expertise is of value, but focusing on the issue is also of value.
• Ernst is not the only researcher raising these issues. This is not a one-guy-versus-the-consensus situation.
• The results Chiropractic reports from the Task Force do not disagree with the results it reports from Ernst. This is not a battle between two sources only one of which can be right.
• The cited source for the Task Force, which is the executive summary, omitted the bolded text, indicating that they did not consider that text to be part of the bottom line.

Eubulides (talk) 03:11, 16 March 2008 (UTC)

Then we shall use Cassidy et al. if you feel the Task Force is not appropriate. Either way, Ernst is undue weight now whereas the findings of the report should be stated in their full context. Again, you have not addressed my concern which is a severe underplaying of the research done by the multi-disciplinary panel of researchers, not merely an anti-chiro MD in Ernst. We should restore the full findings re: stroke issue. I'm all for brevity as well, but just like Doctorisin is mentioned; the safety section seems have the appeal to fear fallacy. EBDCM (talk) 18:21, 16 March 2008 (UTC)

Cassidy et al. (PMID 18204390) is just a primary study. It is reviewed not only by the Task Force executive summary (PMID 18204400) but also by the Task Force neck-pain review (PMID 18204386). Neither of these reviews mention, much less highlight, the point under dispute. The current summary already covers every point mentioned in both of these reviews. We should not second-guess them and highlight a point in a primary study that they did not think was worth highlighting. The general rule in WP:MEDRS, and it is a good one, is that Wikipedia articles should not use primary studies to dispute reliable reviews. There are sometimes exceptions to these rules (e.g., primary studies newer than any review) but these exceptions do not apply here. Chiropractic#Safety already says that the increased risk of vertebrobasilar artery stroke due to spinal manipulation is small and has not been measured; this point does not need to be repeated. Eubulides (talk) 00:46, 17 March 2008 (UTC)

(outdent)Just a suggestion. Add the Task Force phrase "no excess risk" at the end, although doing that makes one want to "puff if up" by saying it's from a notable study...The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern.[62] Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[65]A recent, multidisciplinary study concluded that there was no evidence of excess risk of VBA stroke associated with chiropractic care.CynRNCynRN (talk) 18:58, 16 March 2008 (UTC)

I'd prefer to stick to what the reviews say about this subject, rather than to dip down into the primary studies, for the WP:MEDRS reasons discussed above (this discussion was added after your comment). Eubulides (talk) 00:46, 17 March 2008 (UTC)

The Task Force is an awfully difficult thing to wish away. It is more recent than the reviews. CynRN's suggestion is reasonable. I suppose I could try to write something up. ---- Dēmatt (chat) 03:28, 17 March 2008 (UTC)

Nobody is saying that the Task Force should be wished away. And the Task Force study is not more recent than the Task Force reviews mentioned above. The Task Force's executive summary summarizes the primary source in question, and is cited, heavily, in Chiropractic#Safety. We should not be second-guessing the Task Force's own reviews of its own study. Eubulides (talk) 06:00, 17 March 2008 (UTC)

We are not second guessing the TaskForce's findings, we are just not omitting the full findings and conclusions which has been done in the current revision of safety. Cited heavily? I disagree on that, where in the body of the text is it cited heavily?

Here is all that the main Task Force review (PMID 18204400) says about chiropractic safety:

"There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke."

Chiropractic #Safety restates that as follows:

"Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions."

How could the Task Force review be cited any more heavily than that? Every point that the review makes about safety is also made by Chiropractic#Safety. The intent here is only minor editing for brevity; it isn't supposed to omit any of the points of the original. But if something is missing, what is it? Eubulides (talk) 16:55, 17 March 2008 (UTC)

We either attribute it to the 2 primary sources in full or from the Task Force findings in full.

It's OK for us to attribute something to the Task Force reviews of its own work. I disagree that we should reach down directly into the primary studies. There is no need to use primary studies when we have reliable reviews of those studies. We should use the reviews, and not second-guess the reviewers' opinions. Eubulides (talk) 06:15, 17 March 2008 (UTC)

There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.

Conclusion. VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. Source: http://www.spinejournal.com/pt/re/spine/abstract.00007632-200802151-00019.htm;jsessionid=HdfLnKPmJLn2J6n2Bbcvg0nrhRc0QdwPzbJF016bj1wHWhvBWGRH!-1013551081!181195628!8091!-1

Results The incidence rate of VBA stroke was 0.855 per 100,000 person-years for Saskatchewan and 0.750 per 100,000 person-years for Ontario. The annual incidence rate spiked dramatically with a 360% increase for Saskatchewan in 2000. There was a 38% increase for the 2000 incidence rate in Ontario. The rate of chiropractic utilization did not increase significantly during the study period.

Conclusion In Saskatchewan, we observed a dramatic increase in the incidence rate in 2000 and there was a corresponding relatively small increase in chiropractic utilization. In Ontario, there was a small increase in the incidence rate; however, chiropractic utilization decreased. At the ecological level, the increase in VBA stroke does not seem to be associated with an increase in the rate of chiropractic utilization. Source: http://www.springerlink.com/content/wj7161058u5q1211/

A further point, is that both studies cited here contain a multi-disciplinary research team (DC, MD, PhD, DDS) and was years in the making whereas Ernst is a solo MD who is an anti-chiropractic researcher. So, this "technicality" of preferring secondary sources is kind of bogus here in that the primary study in this case is "preferred" based on its multi-disciplinary panel, breadth, depth, and length of study. EBDCM (talk) 03:16, 17 March 2008 (UTC)

• I very much disagree with the approach of overriding the Task Force's own reviews of its own primary studies, and reaching down into these primary studies and bringing out selected parts to favor one particular pro-chiropractic viewpoint. That is not how reliable articles are written, and completely contradicts the sage advice in WP:MEDRS #Some definitions and basics about not using primary sources to argue with secondary ones. We should respect the judgment of the reliable reviews we have on this subject.
• All of the emboldened text above is taken from primary studies, not reviews. We should be using the reviewer's summary of the work, not the primary studies. Standards for reviewers are higher.

I am not suggesting we override anything, I am for clarity however and making sure that its conclusions and findings are cited in full. The current draft does not do this.

Chiropractic #Safety fully cites every conclusion made by the Task Force reviews. None of those conclusions are omitted. The items in dispute here (bolded above) are taken from primary studies, not from reviews. Highlighting particular statements from particular primary studies, out of the proportion given by the Task Force's own reviews of its own studies, does not follow the WP:MEDRS guidelines and would raise significant POV issues. Eubulides (talk) 17:02, 17 March 2008 (UTC)

How does it raise POV issues when we are citing a multidisciplinary study? MDs are on the list of authors, not so in Ernst. Besides, this is a technicality card you are playing and playing it on a vital issue such as SMT and stroke is not appropriate in this context. This continual objection to Cassidy et al. and Haldeman et al. (studies which are far more robust in depth, breadth, referencing, consensus, and notability) while Ernst gets a free ride is really not the best way to be trying to achieve any consensus here. Let's go with the most robust research available, not a hardline interpretation of MEDRS guidelines. EBDCM (talk) 00:23, 19 March 2008 (UTC)

It doesn't matter how many disciplines were involved in the primary study. What matters is that it is a primary study, whose main points are summarized in a reliable Task Force review. We should rely on that review and not substitute our own opinion about what the main results of the primary study are. This is not simply a matter of WP:MEDRS; it's only common sense. One can easily find many high-quality primary studies to support a wide range of opinions about chiropractic. We need to rely on reviews to help us find the way. It is not reliable to search for primary studies whose results look right to us; that is a procedure that clearly has POV issues. And this is not an issue of giving Ernst a free ride: Ernst cites lots of primary studies too, and those primary studies are not cited in Chiropractic #Safety either. The two supportive-of-chiropractic primary studies do not have far more more depth, breadth, etc., than the studies and reviews that Ernst cites. Eubulides (talk) 09:05, 19 March 2008 (UTC)

• I continue to object to the characterization of Ernst as a "solo MD". Ernst is not alone in criticizing the safety of chiropractic.

Noted, but Ernst's review pales in comparison to the depth, breadth and length of safety put into either the task force report or the individual papers. I read the Ernst paper yesterday and I was pretty shocked at how many fallacies were used in that "review". If that is what passes for MEDRS standards, than it is very poor. For example, Ernst cites chiropractic "core concepts" and cites an alt-med text written by MDs that describes chiropractic philosophy which was very, very one sided and was about 50 years behind the times. Also, a lot of the "critical" analysis is on straight chiropractic and I would suggest it mischaracterizes it as well

• Ernst's review (PMID 17606755) is all about safety; the Task Force reviews are about many subjects and devote only a small fraction to safety. Ernst's review contains far more material about safety than the Task Force reviews do.
• Ernst's review does not contain the phrase "core concepts" and does not mention straight chiropractic. Are you sure you were reading the right paper?

Eubulides (talk) 17:13, 17 March 2008 (UTC)

When Ernst describes chiropractic the way he does, he is describing straight chiropractic. You don't need to be a rocket scientist to figure this one out. Also, the "books" and "papers" cited by Ernst is chiropractic "research" done by MDs (who have historically tried to squash chiropractic and chiropractors, see Wilk vs. AMA and you can figure out the rest yourself. Just to note; I have gotten by membership back at University of Toronto libraries so I can now fact check the articles you are citing. So, I would be careful of including studies that do not have adequate multidisciplinary representation. EBDCM (talk) 00:23, 19 March 2008 (UTC)

Ernst's review (PMID 17606755) is generic to spinal manipulation; it does not push straight chiropractic (it does not discuss subluxations, or innate intelligence, or anything like that). There is no rule that primary studies or reviews must be multidisciplinary. Extremely high-quality work can be done by teams within a single discipline. It would be inappropriate to reject a review simply because it didn't have (say) a chiropractor coauthor. Eubulides (talk) 09:10, 19 March 2008 (UTC)

Extremely high work was not done by the author in this discipline. We are not rejecting it; just giving the weight it is due.

• There are several high-quality studies on both sides of this issue. Why push two pro-chiropractic ones?

Ernst is not a high quality paper. It focuses almost exclusively the vitalistic, metaphysical and straight viewpoint of chiropractic (the minority nonetheless). In describing chiropractic theory is refers to dated Palmer concepts which Palmer himself repudiated and does not even take into account modern theories. It failed to include the most recent definition of subluxation (WHO 2005) despite the fact it cited definitions from 1996-2002. Considering it was published in 08, this seems like a deliberate attempt to omit anything that would make chiropractic look like a reasonable profession. Also, a "critical" evaluation requires an objective look at the both sides of the picture and Ernst has clearly not done that. Even his conclusions are highly suspect, suggesting that SMT is not grounded in science and that all of a sudden chiropractic needs a higher standard that other professions in that it has not been proven beyond a shadow of a doubt. What is the success of surgery for LBP? Why is Ernst applying a double standard and moreso, why do you endorse it? EBDCM (talk) 00:23, 19 March 2008 (UTC)

Again, this seems to be an attack on the wrong paper. Ernst 2007 (PMID 17606755), which is the paper Chiropractic #Safety cites, does not match the above description. I disagree with the attack, but regardless of whether one agrees or disagrees with it, the attack is irrelevant to what's in Chiropractic#Safety now. Eubulides (talk) 09:15, 19 March 2008 (UTC)

I'm not "attacking" the wrong paper, I'm critiquing it. Please use better language, you said that word 3x in 2 sentences. EBDCM (talk) 23:49, 19 March 2008 (UTC)

The studies aren't pro-chiropractic, they address the topic at hand, namely manipulation and VBA. And, after careful analysis of the data, they've (a PANEL of professionals not just DCs or MDs, but BOTH along with PhDs and MANY notable institutions) concluded that there is no excess risk. The Ernst study is not of this caliber, or is it even close. It's a condemnation piece which is hardly objective. It is written by one person, with an agenda, namely to discredit chiropractic at seemingly any cost. At first I had not read the study in question, but after reading it is such a gross misrepresentation of the overall chiropractic picture (its biggest fallacies include of the biased sample and appeal to fear and ridicule). Ernst goes to say how the straights are the minority then dedicates almost the whole paper critiquing them and condemning the majority of the profession who do not share those values or practice styles. It also suggests that many of the critiicisms are directed towards US DCs and mentions in several instances how Canada and Europe "buck the trends". There was at least 3-4 separate mentions of this in the paper yet no mention in safety? Common, Eubulides. Now that I have read the paper in question, you're going to have to justify a lot of the garbage in there that is included in safety and why you chose certain passages and not others that provide a more balanced, objective view.

• The primary studies in question have pro-chiropractic results. Other primary studies have results that go the other way. Why emphasize detailed claims from two pro-chiropractic studies, when even the Task Force reviews do not mention those claims? Why emphasize pro-chiropractic primary studies, while ignoring the other side?

Pro-chiropractic results? Why the false dichotomy again? It could have been inconclusive or negative. I'm not saying we ignore Ernst, let's just give him the weight he deserves until his paper(s) are as good as Cassidy's and Haldemans. At least they INCLUDED MDs as part of the review whereas Ernst does not include DCs to be part of his research. EBDCM (talk) 00:23, 19 March 2008 (UTC)

The edits being proposed in bold above are attempting to highlight words in these primary studies that support chiropractic, even though reliable reviews by the Task Force do not mention the words at all. Highlighting these words would substitute Wikipedia editors' POV for the viewpoint of published experts in the field. That is not a wise thing to do. It doesn't matter whether DCs appear on the author list; what matters is whether the reviews are reliable sources. Ernst's reviews clearly fill that bill, as do the Task Force reviews. Eubulides (talk) 09:20, 19 March 2008 (UTC)

Those aren't my words Eubulides those are the verbatim conclusions of the authors. Reliable sources also include Haldeman et al. and Cassidy et al. These don't "support" chiropractic (the profession, remember, Eubulides) rather it merely states that the risk of SMT to the cervical spine does not result in an increase in relative risk. Surely you know better than to confuse the two. EBDCM (talk) 23:49, 19 March 2008 (UTC)

• The Task Force's careful analysis of the data was published in its reviews. The primary sources are just single studies, and do not represent the opinion of the entire Task Force. Let's stick with the reviews.

Primary studies are sometimes better and more robust academically and in notability than secondary studies. This is the case here. It's also has MD co-authors. Does Ernst have another discipline as part of his review?

The Task Force's primary studies are not stronger than its reviews. Its reviews are much stronger and they rely on far more sources. This is not an issue of Ernst or MD co-authors or anything like that. Ernst isn't even involved at all. This is an issue of the Task Force's own reviews of its own work. Eubulides (talk) 09:22, 19 March 2008 (UTC)

Sorry, disagree. We wouldn't be here if your safety edit had provided OK weight, but it did not and was a fear mongering edit that needlessly plays up a small risk. EBDCM (talk) 23:49, 19 March 2008 (UTC)

• The Ernst review does not talk about straights and does not contain the phrase "buck the trends". Apparently there is some confusion here, and the wrong paper was being read. Please follow the reference to Ernst 2007 given in Chiropractic#Safety.

I was reading the 2008 paper, I will read the 2007 one tonight although I doubt it will cut from a different cloth than his previous "reviews" on chiropractic, SMT and safety.

Eubulides (talk) 17:27, 17 March 2008 (UTC)

• Suppose Chiropractic#Safety reached down into some of the primary studies cited by Ernst and heightened their individual results more than Ernst himself does. Would that seem like neutral coverage of the issue?

Garbage in, garbage out. We have enough editors here versed in literature reviews and we can discuss the papers and their merits/validity or lack thereof. We should do and review the individual papers if need be; but the stuff cited by Ernst and his entire article is nothing more than anti-chiropractic propaganda and the fact that you're vouching for it is, IMO, lamentable.

• When we have reliable reviews of individual primary studies, we should prefer those reviews. The opinions of Wikipedia editors should not override the opinions of published expert reviewers. (If we were really that good at reviewing, we should be publishing those papers!…)
• Ernst's review represents serious criticism that should not be ignored by any neutral summary of chiropractic safety issues.

Eubulides (talk) 17:34, 17 March 2008 (UTC)

I'm not suggesting we ignore Ernst. We should state his concerns briefly and succintly. As long as it catches the "spririt" of his message. We don't need to get into a stats pissing match here. The safety, as currently written does not adequately capture the weight, importance and spirit of the conclusions. This issue and study has been in the making for 6+ years now and your edit reduces it to 1 line. 1 million patient years of data was studied. Can Ernst say the same, or any other paper for that matter? Common. EBDCM (talk) 00:23, 19 March 2008 (UTC)

The Ernst review, like the Task Force review, relies on many, many primary sources. I agree that we need not get into a stats match here; we can simply report what both reviews say, and move on. That is what Chiropractic#Safety does now. Eubulides (talk) 09:24, 19 March 2008 (UTC)

The Ernst review, unlike the Task Force review, only cites mainstream med lit. Hence, it egregiously misses tons of literature done by chiropractic researchers. It's invalided based on this. At least Task Force used a full review all ALL the relevant literature then got a MULTIDISCIPLINARY panel to review it. Not so with Ernst. EBDCM (talk) 23:49, 19 March 2008 (UTC)

Eubulides (talk) 06:15, 17 March 2008 (UTC)

Eubulides makes good points. I would only support adding one additional sentence to support the Task Force, as it was a notable study and...more or less as a peace offering and to underscore the impression of "safety". (Not very scientific, I know)CynRNCynRN (talk) 06:25, 17 March 2008 (UTC)

We shouldn't reach down into the primary studies. Nor should we add puffery about how great the Task Force is (any more than we should add puffery about how great Ernst etc. are). However, I would favor adding another sentence about safety, taken from a review. How about adding this sentence?

Risks can reasonably be considered slight when compared to all forms of medical treatment.

Eubulides, please do not continue down this path. We have heard it before and many of us disagree. The primary studies in this case are much higher quality papers than Ernst and anyone with any degree of scientific and lit background who read the papers in question would agree. Nor is anyone adding any puffery. We are providing suffiicient context as WHY it should be notable and WHY readers would care of who or is concluding. There are major omissions in the current version and they need to be rectified ASAP. EBDCM (talk) 15:44, 17 March 2008 (UTC)

• The primary studies are not "much higher quality" than Ernst 2007. First, they are primary studies and not reviews, so they are not directly comparable. Second, both sets of papers are high quality; it is not at all clear that one is higher quality than the other. It appears from the discussion above that you were reading some paper other than Ernst 2007; perhaps that explains our difference in opinion here.

Again, a technicality. The studies are much better than Ernst 07 for several reasons: 1)multidisciplinary input 2)associated with WHO and 100+ universities and public health institutions, 3) has provided a much more intense and competitive lit review process for citations inclusion 4) has studied 1 million years of patient data, 5) has compared stroke rates with other health professionals 6) has some of the best authorities in the world on VBA stroke as authors 7) is part of of international task force 8) etc.... EBDCM (talk) 00:23, 19 March 2008 (UTC)

The primary studies do not review nearly as many sources as Ernst 2007 does. The primary studies were not done by the WHO, nor by 100+ universities, etc., etc.; they were just primary studies. Ernst 2007 is published in a high-quality journal. It is not fringe opinion, or anything like that. Chiropractic should not ignore Ernst's criticism, nor should it argue with it by going to the lengths of citing primary studies that disagree with it. Eubulides (talk) 09:36, 19 March 2008 (UTC)

You're making this needlessly personal. Ernst is cited in the safety. His points are noted. You are misrepresenting my argument (again) by stating that we are "ignoring it" and that I'm resorting to citing a "primary" study. Please do not do this again. This is the third time I've asked. EBDCM (talk) 23:49, 19 March 2008 (UTC)

• Providing the context for pro-chiropractic results, while failing to provide similar context for the other side, is not neutral.

You are misrepresenting my argument. Please do not do it again. EBDCM (talk) 00:23, 19 March 2008 (UTC)

I understood "We are providing suffiicient context as WHY it should be notable and WHY readers would care of who or is concluding" to stand for a proposal to include results from the primary studies, and to give information that might include who did the primary studies, what their affiliations and degrees were, how these primary studies were multidisciplinary, and so forth. If that was not the proposal, I apologize for misinterpreting it. Eubulides (talk) 09:39, 19 March 2008 (UTC)

I think this was a misunderstanding. EBDCM (talk) 23:49, 19 March 2008 (UTC)

• Providing context for both sides in the main text would weaken the article. Among other things, it would lengthen Chiropractic#Safety and make it appear to be a more-serious issue than it really is. The typical reader wants to know about safety, not about the various researchers involved who are working on safety issues.
• It is not a major omission to put authorship material in footnotes; that's where authors belong.

Eubulides (talk) 17:46, 17 March 2008 (UTC)

If we have to sacrifice brevity for clarity than so be it. EBDCM (talk) 00:23, 19 March 2008 (UTC)

There is nothing unclear about putting authorship material in footnotes. That's the standard style, and is expected in Wikipedia. Eubulides (talk) 09:41, 19 March 2008 (UTC)

This could be appended to the 1st paragraph of Chiropractic #Safety. This sentence was in the "Safety 3" draft and got put into Chiropractic #Safety, but Dematt removed it a couple of days ago; I don't know why (there wasn't anything in this talk page about it). The advantage of this sentence is that it's a new point; the stuff we're talking about from the primary studies is merely emphasizing points that are already in Chiropractic #Safety. Eubulides (talk) 06:58, 17 March 2008 (UTC)

If risks are slight/minimal why is it described in 10 sentences? If the risks of SMT for neck pain are less that NSAIDS or surgery why isn't this mentioned? The current edit is too close to an appeal to fear fallacy and is undue weight. EBDCM (talk) 15:44, 17 March 2008 (UTC)

• Risks are also slight for vaccines but Wikipedia has thousands of words about vaccine safety in articles like Vaccine court, Vaccine injury, Vaccine Adverse Event Reporting System, Vaccine Safety Datalink, MMR vaccine controversy, Thiomersal controversy, Vaccine controversy, and many others. There is genuine public concern about safety, and this concern is stimulated by a few real problems. The situation for chiropractic is similar. Wikipedia should cover the issue: even though the risk is small, it is real.
• The sentence proposed above ("Risks can reasonably be considered slight when compared to all forms of medical treatment") makes the point you mentioned and cites a review. Do you like the proposed text? If not, what text and citation would you prefer instead?

Eubulides (talk) 18:02, 17 March 2008 (UTC)

I like this addendum:"Risks can reasonably be considered slight when compared to all forms of medical treatment" That alludes to the risk of NSAIDs, etc. The reason some editors want this topic mentioned is that it is currently very controversial and commonly written about in medical journals. I think it's been presented quite neutrally and not fear-mongeringly.CynRNCynRN (talk) 17:56, 17 March 2008 (UTC)

More on vaccine issue

More on vaccine issueI am afraid the anti-vax question needs to be covered. Why not explain this interesting and notable quirk in chiropractic? The range of objection to vaccines goes from the libertarian stance to a anti-vax religious zeal, as Craig Nelson points out. It's a vital public health issue.CynRNCynRN (talk) 06:36, 17 March 2008 (UTC)

I agree. It's not as cut and dry as an issue, and the fact that there is a vaccine controversy page suggests this as well. It should be handled better than it currently is here and we should not have excess weight of it either. I also object to not acknowledging a historical softening towards vax and that being neutral on a given subject that falls outside the scope of practice is not a horrendous thing. EBDCM (talk) 15:44, 17 March 2008 (UTC)

I also would not object to expanding the coverage of vaccination to include changes in attitude with time. Both longer-term trends (since the days of D.D. Palmer\) and shorter term trends (slight hardening of position against vaccination since the early 1990s) should be covered. Eubulides (talk) 18:02, 17 March 2008 (UTC)

From the WCA in 2000 in response to the Campbell article in Pediatrics: "Ms. Fisher(who wrote anti-vax book A Shot in the Dark) sees this as the start of a serious confrontation between the two professions. "The battle lines are drawn and are clear," she states. "They are going to go after chiropractors who treat children and especially go after any chiropractor who does not recommend vaccination...Our message is getting increasingly favorable treatment in the media -- the other side knows we are gaining ground and they know we have been able to stay the course in large part because of chiropractic support in the past five years," she observes.

After publication of the pediatrics articles, The World Chiropractic Alliance sent a special Action Alert to its members and others on its special e-mail list. Dr. Terry Rondberg, WCA President, (stated) ... "the key in this instance is for all the major chiropractic organizations to work together to present a solid front to the medical profession and to the public," he stated. "We are only as strong as our weakest link and if the medical and drug industries can find even one organization to back down on this position(anti-vax), they will use it against us." This is recent and reflects what is published on the web and on Youtube by chiropractors.CynRNCynRN (talk) 18:51, 17 March 2008 (UTC)

I dunno, I'm not sure what this stuff about the WCA would add to the article. Obviously a vocal minority of chiropractors oppose vaccination, but the current article already says that. If peer-reviewed journal articles cover the topic, I'd rather use them than citing partisan web sites. Eubulides (talk) 19:15, 17 March 2008 (UTC)

I am not suggesting adding this to the article. I am making the point that chiropractic hasn't 'softened' that much toward vaccination, at least in the media and that this was a 'call to arms' regarding the issue. Obviously, it doesn't prove that the profession responded to the call.CynRNCynRN (talk) 20:04, 17 March 2008 (UTC)

(outdent)Being neutral on a public health measure like vaccine is a dicey position. When chiropractors are primary care providers and commonly treat children, any hedging about the effectiveness of vaccines may sway the parent against them. High percentages of vaccination are imperative to keep several common childhood diseases at bay and protect the immunocompromised individuals in our society (for whom vaccines may be contraindicated). It's not that the rare adverse effects need to be covered up, but the evident advantages should be presented, as well. Although vaccine is not scope of practice for chiropractors, who says they can't be promoters of them as a preventive measure? (I'll jump off my soap-box, now) Anyway, I think the article presents the situation pretty acurately without besmirching the 'evidence-based' rational chiropractors. We could go on and on about 'germ theory' vs 'individual liberty' as reasons for anti-vax positions vs 'anti-establishment', etc, but that would just enlarge the section needlessly.CynRNCynRN (talk) —Preceding comment was added at 00:00, 19 March 2008 (UTC)

"Although vaccine is not scope of practice for chiropractors, who says they can't be promoters of them as a preventive measure?". The regulatory colllege says so. They are not allowed to talk about vaccines at all, as any discussion on that front should be done with their medical doctor. DigitalC (talk) 00:44, 19 March 2008 (UTC)

Science section needs a rewrite

Agree. Also the "science" section needs a complete rewrite. The bulk of scientific reports in Cochrane and elsewhere show chiro has no effect on a range of conditions. The article needs to reflect this. The philosophy of science lecture is superfluous. Mccready (talk) 12:58, 12 March 2008 (UTC)

Here is a suggestion for improving Chiropractic #Scientific inquiries. Looking at Scientific investigation of chiropractic, its main article, it appears that the main scientific topics are (1) safety, (2), effectiveness, (3) risk-benefit and/or cost-benefit, (4) philosophical issues, and (5) history (that is, history of the interaction between science and chiropractic). I suggest the following disposition of this material:

• Expand Chiropractic #Safety into a new section Safety, effectiveness, and cost-benefit that includes topics 1 through 3 as subsections.
  • The safety subsection could start with the text in #Safety 3.
  • The effectiveness subsection could be written from the sources in #Sources for effectiveness.
  • The risk-benefit / cost-effectivness subsection could be written from the sources in #Sources for risk-benefit and cost-effectiveness.
• Move philosophical discussion (topic 4) into Chiropractic #Philosophy. Some discussion of the philosophy of straight chiropractic versus the philosophy of science is appropriate there; perhaps the existing discussion is enough, or perhaps it can be improved.
• Move historical discussion (topic 5) into Chiropractic #History.

Once this is done, there will be no need for a "Scientific inquiries" section, and no need to rewrite it; though there will be a need to rewrite the moved material. Eubulides (talk) 16:32, 12 March 2008 (UTC)

Very ambitious! Your plan sounds logical. Are you going to tackle it yourself, or do you want to divvy it up?CynRNCynRN (talk) 18:59, 12 March 2008 (UTC)

Help would be very much appreciated. The first subtask (safety) is done I hope. Would you like to volunteer for one or more of the remaining tasks? I think subtask 3 (cost-benefit) will be hardest, as #Sources for risk-benefit and cost-effectiveness is still incomplete; a more-extensive search needs to be done. Subtask 2 (effectiveness) involves reading the sources in #Sources for effectiveness and distilling them down to something short and sweet; this is easier but is still a nontrivial task that requires access to sources. The remaining tasks are the easiest, I hope, since no access to sources is required. Eubulides (talk) 19:46, 12 March 2008 (UTC)

The safety section does not need to be expanded. . . to the contrary, it should be much shorter. Why? Because there is no real big safety issue with chiropractic. . . It is actually remarkably safe. . . I do not even think "safety" warrants its own section. Again, the safety issue is only notable because chiro-opponents play up the infinitessimal risks. Giving this much room to their minority-opinion agenda is a violation of NPOV.TheDoctorIsIn (talk) 01:02, 13 March 2008 (UTC)

There must be some confusion here. The idea is to shrink the safety section, not grow it. The plan is to replace the current Chiropractic #Safety (505 words, by my count) with #Safety 3 (250 words). That's a more-than-50% reduction. Eubulides (talk) 06:49, 13 March 2008 (UTC)

More and more it seems like this article would be turning into a condemnation of chiropractic rather than a neutral discussion of it if we were to follow many of the suggestions above.TheDoctorIsIn (talk) 01:04, 13 March 2008 (UTC)

Which suggestions are those? Please provide details. Eubulides (talk) 06:49, 13 March 2008 (UTC)

Doctorisin, I too share your sentiments and have raised this issue as well. Regarding science rewrite I too agree a rewrite is in order and we should use the CCGPP sources as it provides the most comprehensive, evidence based review of scientific literature as it pertains to chiropractic clinical practice on UE, spinal, LE and non-NMS conditions.

http://www.ccgpp.org/lowbackliterature.pdf http://www.ccgpp.org/upperextremity.pdf http://www.ccgpp.org/2.pdf http://www.ccgpp.org/softtissue.pdf

If someone can find a more comprehensive source and a review of chiropractic literature they should present it, otherwise these documents should suffice as the work has already been done for us. EBDCM (talk) 00:32, 16 March 2008 (UTC)

The first source (lowbackliterature.pdf) is already listed in #Other musculoskeletal problems. The 3rd source (2.pdf) is already listed in #Other problems. The other two sources are still in draft form, and shouldn't be cited in Wikipedia until their final versions are available. #Sources for effectiveness contains many other high-quality reviews of the effectivness of chiropractic. Eubulides (talk) 02:14, 16 March 2008 (UTC)

They're still V and RS and should be included. It's the most comprehensive review available and gives the complete picture, not merely a medical one like the sources from exclusively mainstream med. journals. It meets inclusion criteria and will suffice until the final draft comes in. EBDCM (talk) 02:39, 16 March 2008 (UTC)

They are not for attribution, while in draft status. One of them explicitly says this; the other is in the same category. That review is intended only to express the opinion of CCGPP; it is not the complete picture. Eubulides (talk) 04:55, 16 March 2008 (UTC)

The literature review has been done and we can grab the studies and appropriate conclusions. The review is a lit synthesis and provides us with all the necessary sources and references to make adequate conclusions. Otherwise we are left with mainstream med speaking on behalf of chiropractic and that is not appropriate given the fact we have an evidence-based lit review that is more pertinent to the topic at hand. EBDCM (talk) 18:52, 16 March 2008 (UTC)

It would be OK to refer to studies that these drafts refer to, so long as we don't cite the drafts themselves. More generally, mainstream medical sources and chiropractic sources should both be used. This is not an area where one set of sources completely dominates the other. Eubulides (talk) 00:50, 17 March 2008 (UTC)

Cochrane. Bandolier. I did a lot of work on the science section before the 'defend chiro at all costs lobby' bulldozed along. The article needs to list up front the diseases chiros treat then list the evidence for whether chiro works for these diseases or not. It's that simple. Chiros claim efficacy for all sorts of things. You name it they treat it: asthma, rheumatoid arthritis, infantile colic, urinary incontinence, dysmenorrhoea [12], breast cancer (chrissakes). The reader needs to know this and know what the science says. 125.168.45.230 (talk) 00:38, 16 March 2008 (UTC)

#Sources for effectiveness lists four Cochrane sources, including the dysmenorrhea citation you mention. The Cochrane sources are quite reliable and their results are worth referring to. Are there other good sources aside from those already listed in #Sources for effectiveness? Eubulides (talk)

Thanks anonymous, but those aren't articles per say. DCs treat between 85-95% neuromusculoskeletal conditions, and the article will reflect this otherwise it's an undue weight issue. Regarding your statement that DCs claim to treat various conditions, do you have any evidence of this or is this hearsay? Hawk et al. provides a comprehensive review of all non NMS conditions which will suffice.

There is plenty of evidence that chiropractors claim benefits for asthma etc. See, for example, Pollentier & Langworthy 2007 (doi:10.1016/j.clch.2007.02.001), which reported that more than half of the surveyed chiropractors thought chiropractic intervention benefits gastrointestinal complaints, pre-menstural syndrome, infantile colic, middle ear infection, and asthma; and that significant minorities thought it benefited osteoporosis, obesity, hypertension, and infertility. Eubulides (talk) 02:36, 16 March 2008 (UTC)

Hawk et al. adequately covers this topic. Regardless, 85-95% of DCs treat NMS complaints. The evidence is inconclusive; not enough to suggest it is effective, not enough evidence to suggest it is not. After all, there are many case studies and over 100 years of claims that spinal manipulation could help alleviate symptoms not related to strictly NMS. Also, see my comment below regarding the HOW and WHY of non-NMS care. A lot of eat is to provide symptomatic relief. We need to be careful here with weight issues again. History is already riddled with vert sub stuff as though it was the only thing in chiropractic history (undue weight). EBDCM (talk) 18:48, 16 March 2008 (UTC)

Also, perhaps you are confused regarding HOW and WHY DCs treat non-NMS conditions. From the OCA: Chiropractic care may also be used to provide symptomatic relief for patients with chronic conditions. According to patient surveys, by treating the neuromusculoskeletal elements of such disorders, chiropractic treatment has been shown to improve the general well-being of the patient. This falls in line with the philosophy of chiropractic in treating in a holistic manner, which this is an example of. EBDCM (talk) 01:04, 16 March 2008 (UTC)

It is difficult to try and decide what an entire profession believes. That would take a really long article. McCreedy, don't forget to sign in ;-) -- Dēmatt (chat) 03:46, 17 March 2008 (UTC)

Manga report notes

I too, think the Manga report and worker's comp reports should be merged with the other cost-effectiveness studies. I would like to see a full text copy of the Manga report. I have read that the conclusions are not supported by the research. For instance, manipulation was studied, not chiropractic manipulation, and that most of the studies reviewed were not chiropractic studies, but some other type of practitioner. If this is true, I don't understand why the Manga is such a big deal? Try as I might, I could not find a full text, just the summary.CynRNCynRN (talk) 04:19, 14 March 2008 (UTC)

I could not find a copy of the original Manga report online. You may be able to get a copy by writing Pran Manga directly. It should be noted that the report was controversial when it came out; see, for example:

• Lowry F (1994). "Orthopedists have bone to pick with economist over report on chiropractic". CMAJ. 150 (11): 1878–81. PMID 7802764.
• Manga P, Angus D (1994). "Report on chiropractic". CMAJ. 151 (8): 1107–8. PMID 7922936.
• Chapman-Smith DA (1994). "Report on chiropractic". CMAJ. 151 (8): 1108. PMID 7802806.
• Hoaken PC (1994). "Report on chiropractic". CMAJ. 151 (8): 1110. PMID 7922937.
• Tardif GS (1994). "Is the chiropractic management of low-back pain the solution? What can physicians learn from the Manga report?". CMAJ. 151 (9): 1247–9. PMID 7954171.
• Manga P (1994). "Defending the Manga report on the chiropractic management of low-back pain". CMAJ. 151 (9): 1250–1. PMID 7954172.

Chiropractic #The Manga Report does not cover this controversy; it gives only Manga's side. At this point the Manga report is a historical curiosity (we have later and better studies in #Newer cost-effectiveness sources). If the report is important for historical reasons, it could be briefly mentioned in Chiropractic #History, along with a brief summary of the controversy it engendered, and perhaps (to avoid bias) similar treatment of a vintage anti-chiropractic study. We can use them as examples of the historical feud between chiropractic and conventional medicine. Eubulides (talk) 05:59, 14 March 2008 (UTC)

Thanks for the links. Manga is still on a many chiropractor's websites, on casual perusal, to prove cost-effectiveness. It would be interesting to include some of the criticisms.CynRNCynRN (talk) 17:49, 14 March 2008 (UTC)

I just got a email reply from Professor Manga himself! His full report is available in book form (5 copies left) postage included. He says it is not online. I think I'll pass, I have too many books in the house.:-) His email is above for those who want it.(Nice guy, I didn't think he'd take the time!)CynRNCynRN (talk) 02:32, 16 March 2008 (UTC)

I forgot to say, the report is $20, postage included.CynRNCynRN (talk) 03:13, 16 March 2008 (UTC)

Revision to "Practice styles"

Here is a modified version of Chiropractic #Practice styles and schools of thought that attempts to address issues described in #POV issues as of 2008-03-12 above, along with improving some wording. One change I'd like to make is to shorten the section header, as per the usual Wikipedia dictum that section headers should be short. Eubulides (talk) 20:18, 13 March 2008 (UTC)

This revision uses the following citations which are already present in other sections of Chiropractic:

(start of proposed revision to Chiropractic #Practice styles and schools of thought)

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Practice styles

Common themes to chiropractic care include holistic, conservative and non-medication approaches via manual therapy. Nevertheless, there are significant differences amongst the practice styles, claims and beliefs between various chiropractors. Those differences are reflected in the varied viewpoints of multiple national practice associations. There are two main groups as well as two minority off-shoot groups.

Straight

Straight chiropractors are the oldest movement. They adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an Innate intelligence within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies. Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

Mixer

Mixer chiropractors are an early offshoot of the straight movement. This branch "mixes" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixer chiropractors incorporate mainstream medical diagnostics and employ myriad treatments including joint and soft tissue manipulation, electromodalities, physical therapy, exercise-rehabilitation and other complementary and alternative approaches such as acupuncture. They tend to focus more on the neuromusculoskeletal system but also treat non-neuromusculoskeletal conditions as well. Mixers tend to use more mainstream scientific methods and descriptions as opposed to metaphysical ones.

Minority

Objective Straight chiropractors is differentiated from traditional straights mainly by the claims made. While traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases, objective straights only focus on the correction of chiropractic vertebral subluxations. Their guiding principles are summed up as: "We do not want to diagnose and treat diseases, even diseases of the spine." and "We do not want chiropractic to be practiced as an alternative to medicine." They encourage their patients "to see a medical physician if they indicate that they want to be treated for the symptoms they are experiencing or if they would like a medical diagnosis to determine the cause of their symptoms." Most objective straights limit treatment to spinal adjustments.

Reform chiropractors are a recent evidence-based off-shoot of mixers who use scientifically-oriented methods and protocols in the treatment of neuromusculoskeletal disorders. Reform minded chiropractors have rejected traditional Palmer philosophy yet retain the holistic, conservative and naturopathic beliefs of chiropractic. Reform DCs are beginning to be integrated into mainstream health care and generally favour an expansion of scope of practice to include limited prescription rights. They do not subscribe to the Palmer philosophy of Innate Intelligence and vertebral subluxations, do not believe that spinal joint dysfunction causes organic or systemic disease, and tend not to use alternative medicine methods.

Range of belief perspectives in chiropractic

perspective attribute	potential belief endpoints
scope of practice:	narrow ("straight") ←	→ broad ("mixer")
diagnostic approach:	intuitive ←	→ analytical
philosophic orientation:	vitalistic ←	→ materialistic
scientific orientation:	descriptive ←	→ experimental
process orientation:	implicit ←	→ explicit
practice attitude:	doctor/model-centered ←	→ patient/situation-centered
professional integration:	separate and distinct ←	→ integrated into mainstream

Scope of practice

It is generally not within the scope of practice of chiropractors to write medical prescriptions. A notable exception is the state of Oregon, which allows chiropractors with minor additional qualification to prescribe over-the-counter drugs. Traditionally, chiropractors have opposed prescription drugs, but in a 2003 survey of North American chiropractors a narrow majority supported prescription rights for over-the-counter medicines. Depending on the country or state in which a chiropractic school is located, some chiropractors may obtain additional training to perform minor surgery or proctology. When indicated, the doctor of chiropractic consults with, co-manages with, or refers to other health care providers.

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(end of proposed revision to Chiropractic #Practice styles and schools of thought.

Comments on proposed revision to "Practice styles"

(Please put comments here.) Eubulides (talk) 20:18, 13 March 2008 (UTC)

I made these changes to #Scope of practice so that its text more-closely reflected the cited sources. Eubulides (talk) 06:36, 14 March 2008 (UTC)

No further comment so I made that change. Eubulides (talk) 07:32, 15 March 2008 (UTC)

I would ask that you please allow more time for the users to properly reply. There's no rush to move these to the main article, and there is a significant omission on what all DCs agree on in practice styles (Coppertwigs) edit. Despite differences, there are basic agreements and unity on the issues you've left out. EBDCM (talk) 02:42, 16 March 2008 (UTC)

Sorry, I'm a bit lost: I don't know what is meant by Coppertwigs edit; the most recent edit by Coppertwig didn't affect the contents of the section in question (just some minor formatting thing). How much time is needed to review a draft section? Eubulides (talk) 05:05, 16 March 2008 (UTC)

The edit that listed the common themes amongst all practice styles. EBDCM (talk) 18:36, 16 March 2008 (UTC)

It's not clear that the common themes need to be listed again, as they were covered in great detail in Chiropractic#Philosophy. If they are mentioned, it should be just a brief reference to "Philosophy". But wouldn't it be simpler just to interchange "Practice styles" with "Treatment procedures"? That way, "Practice styles" would be right after "Philosophy", and we wouldn't need to reprise "Philosophy" at the start of "Practice styles". Eubulides (talk) 00:55, 17 March 2008 (UTC)

The new subsection #Minority added here seems way too long. The citations are weak, and do not indicate that these splinter groups are viable today. Please see Talk:Chiropractic/Archive 16 #Lead for some reliable sources that suggest the groups are not viable today; search for the strings "PSC approach to chiropractic" and "two much smaller groups". Perhaps if this section were abbreviated and moved to Chiropractic #History? At any rate, the citations need to be better, and PPC is a good place to start (as EBDCM suggested on my talk page). Eubulides (talk) 01:04, 17 March 2008 (UTC)

Massive edits against consensus

II reverted Quackguru's massive controversial edits against consensus. . . there are two main groups of chiropractors. . . the other two are off-shoots. . . his version includes poor references as well.TheDoctorIsIn (talk) 08:05, 14 March 2008 (UTC)

Hello. I am interested in getting to the root of the matter here. It seems to me that the main difference between your and Quackguru's edits is the statement about the minority still using dubious methods[13]. From what I understand of science, it is not just about devices and techniques, but theory also. So what we really need to discuss is about chiropractic theory (which is always the basis) and the minority. I don't know minorities from majorities myself, but it would be constructive to get some sort of consensus on what science considers about chiropractic theory. Please don't refer me back to past discussions as this point is definitely something that needs clarification now. Delvin Kelvin (talk) 08:25, 14 March 2008 (UTC)

Part of the discussion is also about changes to the lead. Please see Talk:Chiropractic/Archive 16 #Lead for details. That section also talks about sources for the claims about objective straights and reform chiropractors; so far the evidence is fairly weak that these groups still exist as viable groups, which suggest sthat discussion of these groups should be moved to Chiropractic #History, and be made briefer. Eubulides (talk) 19:19, 14 March 2008 (UTC)

I agree with Eubulides assessment here. No matter how we try to accomodate QuackGurus wording, it just is not supportable by the sources. ---- Dēmatt (chat) 05:48, 15 March 2008 (UTC)

You haven't handled the question at all. What does the scientific community think of the main chiropractic theory? Also, you state that the evidence is weak. Which evidence? I don't think its a matter of accommodation any particular editor's wording. Its a question of answering simple questions that the reader will have in mind. Delvin Kelvin (talk) 01:08, 17 March 2008 (UTC)

There is no "main" chiropractic theory. There is a chiropractic philosophy though which approaches care in a different manner than allopathic medicine. You're also misunderstanding the evidence remark; it was made with respect to the off shoot chiropractic groups, the reformers and the objective straights. EBDCM (talk) 01:14, 17 March 2008 (UTC)

I think part of the problem is that the Wikilink to Talk:Chiropractic/Archive 16 #Lead was broken; I fixed that in my comment above. I agree that there should be a brief summary of the scientific criticism of subluxation; currently that is missing. However, this thread is about a different topic, namely the importance/existence of the reform and objective-straight splinter groups. Eubulides (talk) 01:20, 17 March 2008 (UTC)

I reverted massive edits.[14] We need to talk this over. QuackGuru (talk) 00:30, 20 March 2008 (UTC)

The substantial and massive changes without consensus to the article has continued.[15] QuackGuru (talk) 01:27, 20 March 2008 (UTC)

I agree with this edit anyhow.[16] QuackGuru (talk) 01:30, 20 March 2008 (UTC)

I also concur with this edit.[17] QuackGuru (talk) 01:52, 20 March 2008 (UTC)

I agree with all edits made that was supported by newtral references. Education is taken directly from world health chiro education guidelines, may need proper citation? —Preceding unsigned comment added by 64.25.184.27 (talk) 01:57, 20 March 2008 (UTC)

Prevent subsequent deterioration

I was just rereading the article and came across:"The objective is early identification of mechanical dysfunctions to prevent subsequent deterioration which would result in permanent pathological changes.[24]" in the last paragraph of the philosophy section. Is there any evidence that "subsequent deterioration" can be affected by chiropractic treatment? The reference only gives me the name of the textbook. Is there an accessable ref. for this assertion?CynRNCynRN (talk) 01:49, 15 March 2008 (UTC)

That textbook is not online and is hard to find nowadays. It's better to use a citation that's online. I made this change to cite Vear (readable on Google Books) instead of Strang. This change also rewords for brevity and makes the additional point that prophylaxis is intended to delay (as well as prevent) permanent damage. Eubulides (talk) 04:02, 15 March 2008 (UTC)

Thanks, I'll see if I can look it up in Vear.CynRNCynRN (talk) 16:25, 15 March 2008 (UTC)

Safety again

I started just doing some minor copyediting, but when I got to the Safety section I noticed we had said some things two times and then the order seemed backwards. I ended up making a lot of changes, but I don't think it has changed the meaning, other than being more succinct. I'll put the new one here along with Safety 3. Hopefully it still works for everybody.

Chiropractic care in general, and chiropractic manipulation in particular, are safe when employed skilfully and appropriately. As with all treatments, complications can arise and there are known contraindications and risks.

Spinal manipulation is statistically associated with minor side effects. These include frequent, mild and temporary new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or arm. They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours. Rarely, upper cervical (neck) manipulation can also result in complications that can lead to permanent disability or death; these can occur in adults and children. The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects. Vertebrobasilar artery stroke, the most commonly reported serious complication, is associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.

Absolute contraindications to any form of manipulation (conditions that should not be manipulated) include conditions that are known to result in unstable joints, such as rheumatoid arthritis. Relative complications mean the increased risk is acceptable under some conditions, such as osteoporosis. Although most contraindications apply only to manipulation of the affected region, some neurological signs such as unilateral facial paresthesia, objective cerebellar signs, lateral medullary signs, and visual field defects are indications for emergency referral.

---

Chiropractic care in general, and chiropractic manipulation in particular, are safe when employed skilfully and appropriately. As with all treatments, complications can arise and there are known contraindications and risks.

Absolute contraindications, such as rheumatoid arthritis, prohibit employing manipulation. Relative complications, such as osteoporosis, mean the increased risk is acceptable under some conditions. Although most contraindications apply only to manipulation of the affected region, a few emergency conditions, such as visual field defects, absolutely contraindicate all chiropractic treatment.

Risks can reasonably be considered slight when compared to all forms of medical treatment. Spinal manipulation is statistically associated with frequent, mild and temporary adverse effects; they have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours. The most common minor side effects reported in a 2007 study of cervical spine manipulation were new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or arm. Spinal manipulation, particularly on the upper spine, can also result in rare complications that can lead to permanent disability or death; these can occur in adults and children. The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects. Vertebrobasilar artery stroke, the most commonly reported serious complication, is associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.

-- Dēmatt (chat) 05:49, 15 March 2008 (UTC)

I have a problem with the first sentence, though, and for the life of me I can't figure out a better way to say it:

• Chiropractic care in general, and chiropractic manipulation in particular, are safe when employed skilfully and appropriately.

This tends to make me feel that chiropractic manipulation is safer that chiropractic care? ---- Dēmatt (chat) 06:01, 15 March 2008 (UTC)

BTW, Eubulides, I think your changes were warranted. ---- Dēmatt (chat) 06:01, 15 March 2008 (UTC)

Thanks, I made a few more changes to the contraindication paragraph. It's still too abstruse (how many ordinary readers are going to know what "objective cerebellar signs" are, even with the wikilink?) but it's better than before. Eubulides (talk) 07:15, 15 March 2008 (UTC)

Great job rewording the Safety section. It reads much easier now and is nice and short. No easy task. I suggest making the first sentence "Chiropractic care is (considered)safe when employed skillfully and appropriately". The next paragraph goes on to talk about manipulation, so no need to say it in the first sentence. Then it's not implying that manipulation is "especially safe". CynRNCynRN (talk) 06:36, 15 March 2008 (UTC)

Thanks! And perfect solution to my dilemma! -- Dēmatt (chat) 15:28, 15 March 2008 (UTC)

Good suggestion, particularly since the source says "chiropractic care is safe" without the confusing addition. I made the suggested change. Eubulides (talk) 06:45, 15 March 2008 (UTC)

I ended up making one more change to try and differentiate that spinal manipuation is only one part of chiropractic care as the source tries to point out.

• Chiropractic care in general is safe when employed skillfully and appropriately. There are known side effects, risks and contraindications for it's primary treatment modality, spinal manipulation.

I also switched back the defintion of Absolute contraindications in front of RA, etc. I just think it is better to define the term first then give examples. -- Dēmatt (chat) 16:31, 15 March 2008 (UTC)

Thanks. I made a few more changes which I hope are improvements. I didn't see why Thiel et al. 2007 needed to be cited twice in the same sentence. The contraindications wording confused me; I tried to fix the confusion while preserving the order you preferred. It bugs me a bit to call adverse effects "side effects" (not all side effects are adverse) but I guess it's common enough usage that it's OK. Eubulides (talk) 00:33, 16 March 2008 (UTC)

Looks good, though I took out disc herniations. A little more complicated than that I'm afraid.

(not all side effects are adverse) Exactly. Most of those 'adverse effects' are soreness that you would expect after an hour of exercise. I don't think physical therapists consider those adverse effects either.

---- Dēmatt (chat) 02:54, 17 March 2008 (UTC)

But the cited sources all say "adverse effects" whereas Chiropractic #Safety says "side effects". Shouldn't the article respect its sources here? Why substitute a different term, which means something different? Eubulides (talk) 06:20, 17 March 2008 (UTC)

Is it too awkward to say 'adverse effects or side effects'? Some of the described side effects sound adverse to me...CynRNCynRN (talk) 18:33, 17 March 2008 (UTC)

All adverse effects are side effects, so saying 'adverse effects or side effects' would be a bit like saying 'mammals or animals', which would be even more confusing. The reverse is not true: some side effects are beneficial. The sources talk only about adverse effects, and it's not clear why the article should use the broader term. Eubulides (talk) 18:46, 17 March 2008 (UTC)

Yeah, oops. "Side effect, some of which may be considered adverse...."CynRNCynRN (talk) 07:33, 19 March 2008 (UTC)

The summary

A user has altered my edit to the summary. He wants to say chiros only treat muscular stuff. But the article says that Straights say subluxation is a "primary underlying risk factor for almost any disease" and mixers "treat non-neuromusculoskeletal conditions". Who is right? Me or that other user?

Your edit to the lead put words in that was not attributed to the source. Also, given the fact that this article is under probation and was recently locked; major edits, especially to the lead need to be discussed. Also, you are mis-representing my words, I never said that DCs only treat MSK "stuff" but rather PRIMARILY treat neuromusculoskeletal disorders. 85-95% in fact. It seems that there is potentially some confusion with anonymous and his/her understanding of the topic at hand. EBDCM (talk) 01:33, 16 March 2008 (UTC)

This article was under probation. Someone removed the probation tag. QuackGuru (talk) 01:38, 16 March 2008 (UTC)

The article says Straights say subluxation is "primary underlying risk factor for almost any disease" and Mixers "treat non-neuromusculoskeletal conditions". So what's wrong with saying chiropractic treats human diseases in the summary? —Preceding unsigned comment added by 125.168.45.230 (talk) 03:07, 16 March 2008 (UTC)

The Lead will be undergoing reconstruction and rewording after the rest of the article has been rehashed anyway, so you may as well just leave it be. I don't think it belongs in the lead per se. 202.161.71.161 (talk) 10:08, 16 March 2008 (UTC)

So you are saying I'm right but leave it till later? That doesn't make sense to me. If it's right it can go in now? 125.168.45.230 (talk) —Preceding comment was added at 13:51, 16 March 2008 (UTC)

The section practice styles section needs proper referencing (including the "primarily risk factor for any disease bit". I don't think straights are suggesting that much, the one cause one cure mentality isn't that bad. Perhaps Dematt can shed some light on that issue. Also, I don't see any reference, citation, educational curriculum or anything that suggest that "chiropractic treats human diseases". This type of editing uses the bias sample fallacy and a straw man fallacy. EBDCM (talk) 18:40, 16 March 2008 (UTC)

I don't think straights use the word 'treat' for anything, do they? They adjust subluxations, period. I think back then they would have been jailed if they said they 'treated' anything. But I agree we would need something that references a statement like that. -- Dēmatt (chat) 03:01, 17 March 2008 (UTC)

"Contemporary"

The word "Contemporary" is used twice in Chiropractic#Philosophy, but both times the word is redundant and should be removed. None of the points made are unique to today's chiropractic belief systems; they belong to historical ones as well. Mootz & Phillips goes out of its way to say "Traditional and contemporary chiropractic philosophies both display the dualism of testable principle (materialism) and untestable metaphor (holism)." so it's odd that Chiropractic#Philosophy emphasizes "contemporary" here, with the implication that traditional chiropractic does not have the same dualism. Let's remove the two uses of "Contemporary" in Chiropractic #Philosophy. If there is a need to distinguish contemporary from traditional, it should follow that of the cited source. Eubulides (talk) 01:13, 17 March 2008 (UTC)

Why do you want to squash a word that has vital importance in that it reflects the maturation of the profession? Traditionalists/Straights/Palmerists/Subluxation-based/Principled-based chiropractors are not contemporary chiropractors if they did not attend a progressive school and adopt the contemporary viewpoint (primarily NMS specialists). Mootz and Phillips use this word deliberately. So do departments of chiropractic education (http://www.cmcc.ca/undergrad/Dept_Prof_Ed/Chiropractic_Principles_and_Practice.htm). Contemporary is also used to describe the medical approach to acupuncture which is described in western biomedical terminology (neuroanatomy, neuroscience, anatomy, physiology, etc...) http://fhs.mcmaster.ca/anaesthesia/acupuncturecourses/#who. There is already too much weight given on the minority straight DCs and their views and not enough mention of the contemporary aka reform/evidence-based/mixer view. It's equally as influential as has assumed a defacto leadership role in setting standards of practice guidelines, is geting its research published in mainstream medical journals, chiropractic journals are now beginning to be indexed on mainstream med sites (PubMed) etc. This isn't even counting the ever growing body of chiropractic literature found here http://www.chiroindex.org/. We need to be very, very careful that we do not omit quality chiropractic research that is not indexed in mainstream med. search engines. Chiropractic and Allopathic medicine are separate professions with separate philosophies and separate approaches and separate emphases. My concern again, as stated many times now and that has support of many regular editors here is that there seems to be a push for playing up controversies (i.e. vaccination and safety) and making undue weight for these while small, yet important words that reflect profound paradigms seem to get the boot. EBDCM (talk) 01:54, 17 March 2008 (UTC)

Our problem here is not that there is a medical POV and a chiropractic POV. There is a traditional straight chiropractic POV and a modern/reform/contemporary chiropractic POV that since the 1950s has worked to divorce itself from protectionist vitalistic constructs of straight chiropractic - a construct that was created by BJ Palmer to keep the profession out of the hands of the 'Medical Machine'. BJ died in 1963 and the 'Committee on Quackery' about the same time. Chiropractic made significant changes in the decades since and medicine has had bigger problems than chiropractic. Unfortunately, they also haven't kept up with the changes. EBDCM is a fresh contemporary chiropractor and has no idea why Eubulides keeps combining traditional and contemporary concepts into one, because his concept of chiropractic is totally different. It is the same comparison as traditional medicine - that may use modalities that have no basis in science and scientific medicine - to call a scientific physician a traditional physician would be 'fighting words', while a traditional physician might be flattered to be called scientific. I think it would behoove us to keep that in mind.

The way the article was written before both of you began here was an attempt to present chiropractic as a single entity - only presenting beliefs the two POVS had in common. The reality is that both POVs exist and they are diametrically opposed to each other. So we are slowly changing the article to improve it. We will now need to elucidate the differences as well as the similarities between the two POVs. If we write our article correctly, we inform the public of both POVs without denigrating either. For this reason, it might be better to use the word contemporary when comparing to traditional - and it is reasonable to use the words as we compare the things that make them different and the things that they have in common. It is quite probable that the new jargon will be 'contemporary' as the reform movement tries to divorce itself from the NACM.

-- Dēmatt (chat) 02:36, 17 March 2008 (UTC)

Dematt and EBDCM make some good points. The problem I have is that the sources disagree with them. So, for example, Mootz & Phillips (1997) write:

Traditional and contemporary chiropractic philosophies both display the dualism of testable principle (materialism) and untestable metaphor (holism).

whereas Chiropractic#Philosophy says:

Contemporary chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to materialism

Not only is that "Contemporary" not needed, it's implying that traditional chiropractic is simplistic and not dualistic; this is not supported by the source. Similarly, the second "contemporary" is not supported either.

There's more to this than simply matching the source, though. "Contemporary" is classic newism: it appeals to the assumption that newer is better, which has a whiff of POVism. (Those contemporary chiropractors must be so much better than those old-fashioned chiropractors—that sort of thing.) And part of my worry is that by using advertising words like "contemporary" when they're not needed or even apropos, Chiropractic sounds too much like an advertisement, thus hurting its credibility. Eubulides (talk) 06:38, 17 March 2008 (UTC)

I wouldn't suggest that contemporary is better, it's just a different approach or interpretation, that's all. I don't claim that practicing contemporary chiropractic and contemporary acupuncture is any better than traditional chiropractic and acupuncture although I'm sure it's much more palatable to the scientific and mainstream med communities because the language that describes it's purported effects are based on Western scientific principles and terminology. I disagree that it's an advertisement, but it is a fact that there is shift occuring not only in the US but globally as well. Most of all DC programs outside the US are in universities and offer at least a BSc in chiropractic. They're teaching a contemporary view of chiropractic (aka scientific as opposed to metaphysical, integrated/mixer rather than straight). I don't think the article's credibility is in jeopardy by adding these words but it's credibility is affected by leaving them out and not recognizing this paradigm. EBDCM (talk) 16:11, 17 March 2008 (UTC)

Contemporary feels like 'new and improved' and it's vague... Maybe scientific or evidence-based would be a more accurate descriptive term. What professional would not think that he or she is 'contemporary'?CynRNCynRN (talk) 17:40, 17 March 2008 (UTC)

It's unfortunate that I have to "convince" and "sway" our fellow mainstream editors regarding the word contemporary. It's a synonym for "modern" is a perfectly acceptable contrast and word to the word "traditional" which has been used interchangeably with "straight" chiropractic approaches. If scientific or evidence-based is a consensus preferred term I can go along with it; but know that the term contemporary is being increasingly used by both practicing chiropractors and some articles to describe the modern chiropractic approach that is not subluxation based and is on consistent with EBM principles. EBDCM (talk) 21:40, 17 March 2008 (UTC)

It's not a question of which word is being used to describe modern. It's a question of whether it's appropriate to use "contemporary" to describe a dualism that has been present in chiropractic from the beginning. The source (Mootz & Phillips) says traditional and modern chiropractic philosophies both display this dualism. So why does Chiropractic #Philosophy say only that contemporary philosophy has it? Eubulides (talk) 22:54, 17 March 2008 (UTC)

You're right. What the bigger issue is, should we and can we use the word contemporary to describe the evidence-based approach elsewhere in the article to contrast it with the traditional approach? EBDCM (talk) 00:32, 19 March 2008 (UTC)

"Evidence-based" is much better than "contemporary": it's more specific and it is more commonly used to describe the approach. Let's use "evidence-based". Eubulides (talk) 10:12, 19 March 2008 (UTC)

"Contemporary" is POVish. We can do better than that. QuackGuru (talk) 19:28, 19 March 2008 (UTC)

I find it bizarre to the opposition to the word contemporary. It's no more POVish than the word traditional, quack guru. We'll keep evidence based for now until we hear what the rest of the regular brigade says. EBDCM (talk) 23:36, 19 March 2008 (UTC)

Readable encyclopedic writing

This article needs to be made more understandable to the average reader. Its pretty clear from the links and archives that I have been directed to that there are differences of view between chiropractic theory and practice. The science says that spinal manipulation can be one way of reducing back pain, with a few risks included (as with any internal intervention). Science says that any other use of chiropractic is considered to be what? Dangerous? Pseudoscience? Unethical? Wrong headed?

Clearly chiropractic has some sort of benefit according to science. But as with all science views they use limitations, delineations and they are critical. Please lets have that information presented so it is clear for the reader, both in the lead and in the main body of the article. Delvin Kelvin (talk) 05:01, 17 March 2008 (UTC)

Yes, the terminology is very dense. Can you point out some specific parts that need clarifying? New eyes can be helpful.CynRNCynRN (talk) 06:38, 17 March 2008 (UTC)

I agree with Delvin Kelvin's criticism. Chiropractic is very weak on answering these obvious questions on the subject. Fixing the problem will be tricky, though, as the area is quite controversial. Concrete wording suggestions are welcome. In the meantime you can consult the sources listed in #Sources for effectiveness and #Sources for risk-benefit and cost-effectiveness. Eubulides (talk) 06:44, 17 March 2008 (UTC)

Disagree on a few fronts. First, chirorpractic is not a modality, it's a profession. Next, the CCGPP answers all the scientific questions posed by Delvin Kelvin; we just have to present the findings of the lit review in clear, understandable terms. Otherwise, if it was up to a few editors here the entire article would be a critical condemnation of chiropractic which is mostly directed towards the minority of the professionals most of whom are in the US. The writing in most of the article is pretty easy to understand and the science section is the last one that has not been touched yet for a rewrite. As for your insinuations what science says about chiropractic, we should let the experts on chiropractic (DC/PhDs) care, epidemiology, safety, efficacy have their say. Othewise we our mainstream med editors here will always cite mainstream med "take" on chiropractic which has a pretty big lack of understanding on the modern day chiropractic which was also alluded to by Dematt. EBDCM (talk) 15:52, 17 March 2008 (UTC)

I agree with most of this, except for the implication that the section should be rewritten based on one source or on side's view of the evidence. Mainstream opinion should also be cited and should be given due weight. Eubulides (talk) 18:07, 17 March 2008 (UTC)

Weight is always a sensitive issue around here... just as long as the same standard is applied and enforced over at the medicine article, say if we wanted to present the chiropractic or CAM viewpoint on medical science... EBDCM (talk) 22:24, 17 March 2008 (UTC)

OK, good start. Science gets priority then. I don't see anyone disagreeing with my own recent discovery that chiropractic back manipulations are one scientifically supported method of reducing back pain (with specific science based medical reservations as always). So then we need the science oriented view on all the other applications of chiropractic (some sort of categorized list (or just categories) that have not been supported by science. That will cover the main science findings. Written nice and clear, the reader will be able to get to the core of chiropractic.

Chiropractors/groups themselves are another story, and a complex sociological one by the looks of it. I think we can possibly contain all argument within their own section.

So we know chiropractic has some effectiveness regarding some forms of back pain. What are the main categories of other treatments that they have shown no effect for? I guess a handful of categories would be sufficient. Delvin Kelvin (talk) 06:33, 18 March 2008 (UTC)

See #Specific conditions for some sources and categories. No one has yet had the time to write this section up for Wikipedia; there's rather a lot to read. Eubulides (talk) 06:57, 18 March 2008 (UTC)

Thanks Eubulides, thats helpful. Something more along the lines of a review of research may be more useful than detailed studies though. I think thats the encyclopedic preference. Are there any independent papers that are general reviews? Delvin Kelvin (talk) 07:10, 18 March 2008 (UTC)

#Efficacy in general cites a critical review that has an "Efficacy" section. We don't currently have any cites to a similarly-short overview on the pro-chiropractic side. Eubulides (talk) 07:19, 18 March 2008 (UTC)

Thanks Eubulides. That seems to be a well published science oriented view.

In response to the above request for some ideas on readability; one problem with the article is its main intro to the reader - the lead section. Specifically, the lead section is seems to be more about chiropractors and not enough about chiropractic. This article is supposed to be about chiropractic, and not only chiropractors do chiropractic. Basically in the intro it would make it a lot easier to understand what the subject is if it gave some more condensed information about chiropractic. So as before, if the science results are given a bit more airing there it would help. I am sure this would be acceptable to any pro editors here as the results basically show that there is a positive result for lower back pain. Equally, the science results are scientific and naturally will be critical, as they are of all subjects they investigate. So criticism can be made clearer there also.

Any information on chiropractors and their behaviour should be given a seperate smaller para in the lead. That would help reduce argument there. Of course it can be given larger airing in a large section in the article main body if need be. I'll take a deeper look throughout the article. Delvin Kelvin (talk) 07:49, 19 March 2008 (UTC)

Subluxation debate

In going through the #2008-03-12 issues list, I found a problem in Chiropractic#Vertebral subluxation. It says "certain chiropractic schools still teaching the straight/traditional metaphysical model of subluxation while others have moved towards a contemporary scientific and evidence-based model emphasizing the relationship of structure and function on health" and cites the CMCC 2006–07 course catalog. But this catalog does not say some schools teach straight and others have moved towards evidence-based; it merely says that CMCC's 2006–07 catalog is more evidence-based than before. That's just one college, and it says nothing about straight colleges.

I looked for a better source on the subluxation debate, and found the following:

Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF (2005). "Subluxation: dogma or science?". Chiropr Osteopat. 13: 17. doi:10.1186/1746-1340-13-17.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

I propose that the paragraph cite this source instead of a course catalog, and that the contents be modified to reflect this source more accurately. As a side effect, this will fix the POV problem that got me looking at this paragraph in the first place. Eubulides (talk) 06:52, 18 March 2008 (UTC)

After I asked for a citation on the college, the request for a citation was reverted with the change log "it's in there". However, the citation does not support the claim that "others have moved" towards an evidence-based curriculum. All it supports is the claim that one college moved. To work around the problem temporarily, I made this change to insert a sentence that corresponded more closely to what the source actually says, and to request a source for the other part of the paragraph. Keating et al. 2005 looks like a good source but has to be checked against the Wikipedia text. Eubulides (talk) 21:49, 18 March 2008 (UTC)

Following up on my own suggestion, I added the citation suggested above and modified the text somewhat to match the citation better.

We should use Chiropractic Theories as the scientific source to investigate the chiropractic theories, including those on subluxation. EBDCM (talk) 00:34, 19 March 2008 (UTC)

[18] I disagree with this edit. A lot of the cited text was deleted, it introduced vagueness and lost the meaning of the text, and one of the refs seems to be improperly formatted now.[19] It was confusing for me. There is a big difference between clarity and brevity. QuackGuru (talk) 01:20, 19 March 2008 (UTC)

[20] This edit was not an improvement. The controversial edit deleted cited text. QuackGuru (talk) 03:04, 19 March 2008 (UTC)

[21] I agree with this edit. QuackGuru (talk) 03:07, 19 March 2008 (UTC)

[22] I disagree with this edit. Cited text got deleted again. QuackGuru (talk) 03:15, 19 March 2008 (UTC)

I restored the omitted 2005 WHO definition. I don't actually mind the other edits, it actually nicely illustrates the 2 main viewpoints in the profession and this information is presented in the lead anyways but was not mentioned specifically in the rest of the article. It looks pretty NPOV as well. EBDCM (talk) 05:07, 19 March 2008 (UTC)

I made this edit to restore the cited text that I think is what QuackGuru was referring to; basically, the idea is to briefly explain why subluxation is controversial (otherwise the lengthy summary of who's on what side won't be motivated for the average reader). I also made this edit to more clearly match the text to the citations. Hope this helps. Eubulides (talk) 10:11, 19 March 2008 (UTC)

This helps. The idea is to follow the source carefully and not delete cited text that briefy describes subluxation. QuackGuru (talk) 19:19, 19 March 2008 (UTC)

Hmmm, are you two trying to tag team whis section and hole article so it gives chiropractics a negative slant? The tone written is bad, it makes it sound like some kind of disaproval in many sections here including subluxation, vaccination and especialy safety. I am reading that it is a small risk so why is there so much info? Also, chiropractics does more than adjusting, they do other hands on stuff like muscle work and use physiotherapy machines. —Preceding unsigned comment added by 64.25.184.27 (talk) 01:18, 20 March 2008 (UTC)

Merge from "Scientific investigation of chiropractic"

This change was made without discussion. Template:Mergefrom is supposed to be used with a pointer to a section on the talk page that justifies and explains the proposed merge. That wasn't done here, so it's not at all clear what's being proposed. For now, I removed the template; it can be re-added once there's a serious proposal on the table. Eubulides (talk) 21:34, 18 March 2008 (UTC)

Thank-you for this. I was thinking the same. 208.101.89.150 (talk) 22:41, 18 March 2008 (UTC)

Agreeing that it was a disingenuous edit. . . I removed it from the other article as well.TheDoctorIsIn (talk) 01:57, 19 March 2008 (UTC)

However, according to TheDoctorIsIn, Let's get it the fork out of here! QuackGuru (talk) 02:10, 19 March 2008 (UTC)

My personal opinion of the forked article withstanding. . . Quackguru was still doing it wrong.TheDoctorIsIn (talk) 02:18, 19 March 2008 (UTC)

Agreed. I would like to know why Fyslee reverted my edit which removed this. EBDCM (talk) 05:04, 19 March 2008 (UTC)

As long as there is a main article it is normal practice to link to the main article. QuackGuru (talk) 19:14, 19 March 2008 (UTC)

Deleting Newtral material by world health organization

Why does quack guru insist on deleting cited world health material this is newtral view, verifiable and improves the article? These are facts if not truths. Please discuss.

Orangemarlin and Arthur rubin are tag teaming and abusing wikipedia tools (twinkle) claiming that the reverted edits were vandalism when they were clearly not. How to I report these 2 guys to admins for disruptive editing and false statements in there summaries? 64.25.184.27 (talk) 02:33, 20 March 2008 (UTC)